How to code for lap surgery with ileal conduit

In this "Coding Q&A" column, the Painters also offer suggestions on billing of 52265 (or 52260) when rescue treatment is instilled at the end of the procedure.

My physician is doing a robotic cystoprostatectomy with lymphadenectomy with an ileal conduit for a neobladder. How should this be coded?

Currently, there is no code for laparoscopic cystectomy, nor is there a code for laparoscopic ureteroileal conduit. However, codes do exist for laparoscopic prostatectomy and lymphadenectomy. For this coding example, we will use a total bilateral pelvic lymphadenectomy; you will need to report the code that is appropriate for the service documented.

Based on your indication that a robotic cystectomy with ileal conduit, prostatectomy, and bilateral lymphadenectomy was performed, we would recommend coding this service:

51999 (Unlisted laparoscopy procedure, bladder)

55866 (Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed)

38571 (Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy).

Some have suggested using an unlisted laparoscopic procedure 44238 (Unlisted laparoscopy procedure, intestine (except rectum), in addition to the codes listed above. We recommend that you code similar to an open service, in which the cystectomy and loop are bundled together. This would allow for price comparison to the open procedure 51590 (Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis) during the manual review of the claim for use of an unlisted code.

Others have recommended that you include the lymphadenectomy code in the unlisted service instead of reporting it separately. We recommend listing it separately as there is a current CPT code available to report the service.

Finally, we have heard of some circumstances where a different surgeon will perform the ureteroileal conduit, either via or an open approach or using the laparoscope. If two surgeons are involved, we would recommend that the first surgeon code as above with lower charges to reflect that the ureteroileal conduit is not included. The second surgeon would then code for the ureteroileal conduit separately using code 44238 (Unlisted laparoscopy procedure, intestine [except rectum]) to report a laparoscopic service.

NEXT: Suggestions on billing 52265 or 52260 when rescue treatment is instilled at the end of the procedure

Do you have any suggestions on billing of 52265 (or 52260) when rescue treatment is instilled at the end of the procedure? Although the Correct Coding Initiative does not show it as being bundled, we are receiving denials from our Medicare carrier stating that it is included in other procedures. I appreciate any information.

We will assume that you instilled a combination of drugs into the bladder for the treatment of interstitial cystitis, for which you should report 51700 (Bladder irrigation, simple, lavage and/or instillation). In addition, you performed a cystoscopy with dilation of the bladder, and should record either 52260 (Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction [spinal] anesthesia) or 52265 (Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia), depending on the anesthesia. If the procedures were performed under local, use 52265. If the procedures were performed under spinal or general anesthesia, report 52260.

You are correct that the codes are not bundled and you should not need a modifier. The denial should be appealed since these are two separate procedures. However, your documentation should support that instillation was indeed a separate work effort using a catheter instead of instilling the cocktail through the cystoscope.