How to code an open radical nephrectomy with retroperitoneal lymph node dissection

My urologist performed an open radical nephrectomy with retroperitoneal lymph node dissection. My question is whether I can report CPT code 38780 (with modifier 59/XU) in addition to CPT code 50230 for the radical nephrectomy? Is retroperitoneal lymph node dissection considered regional lymph node dissection? If the approach was laparoscopic instead of open, could one report both CPT code 50545 for the laparoscopic radical nephrectomy and CPT code 38589 (benchmarked to 38780-59/XU)?

Jonathan Rubenstein, MD

It really comes down to the extent of the lymph node dissection and the work that was done and whether the lymph node dissection was performed for staging or for therapeutic purposes.

CPT code 50230 describes “nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy.” As one can see, the descriptor describes that “regional lymphadenectomy” is included in the procedure and cannot be reported separately. If the patient has a tumor and is at risk of spread to the lymph nodes and the lymph nodes are removed, it should not be reported separately. If there is regional lymph node

Mark Painter

enlargement and the removal is performed for cancer control, then it should not be reported separately. However, if there is significant retroperitoneal involvement (such as up to the diaphragm and down to the bifurcation of the aorta) and an extensive surgery is performed to remove all of the lymph nodes as a heroic effort for cancer control, most would agree that would be above and beyond what is described. Therefore, in that unique case one could consider reporting CPT code 38780-59 (or modifier XU for Medicare), which describes “retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure).”These codes are bundled, with unbundling allowed with a modifier—so addition of the modifier should allow for payment. One alternative approach for reporting of the additional effort that can also be considered would be the use of modifier 22 with appropriate notation in the operative note. This approach should be reserved for cases in which the payer does not recognize the 38780-59.

Similarly, CPT code 50545 describes “laparoscopy, surgical; radical nephrectomy (includes removal of Gerota fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy).” Similar to CPT code 50230, removal of regional lymph nodes is included in the descriptor. The descriptor does not state whether this is a staging or therapeutic procedure. Removal of retroperitoneal nodes should only be reported if the procedure is medically extensive enough to warrant separate coding. If this were the case, thenCPT code 38589(unlisted laparoscopy procedure, lymphatic system) benchmarked to CPTcode 38780 seems reasonable; again, one could consider the use of modifier 22 with code 50545 instead of the unlisted code 38589.