Understanding 50320: Radical nephrectomy and lymph nodes

My physician performed an open radical nephrectomy but also removed a 4-cm and a 3-cm peri-aortic metastatic mass. What code or codes should I report? I believe that a radical nephrectomy includes regional lymph node dissection, so I was thinking of reporting 50230.

Jonathan Rubenstein, MD

A coder would need to understand the details of the operative note to confirm the appropriate coding.

50320’s description reads “Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy.”As one can see, the code includes a regional lymphadenectomy if performed. However, the question indicates that the 4- and 3-cm peri-aortic masses may have been noncontiguous masses that were removed in addition to the radical nephrectomy.

Mark Painter

If questions remain after reading the operative note, the physician should be consulted and the note amended to clarify any questions. Once the operation is clear and supported by the documentation, coding would be based on the indicated procedure.

• If the final operative note supports that the radical nephrectomy was performed and that the 4-cm and 3-cm peri-aortic masses removed were separate (noncontiguous) from the renal tissue removed instead of lymph nodes removed with surrounding tissue, one would report 50320 and 49187 (Excision or destruction, open, intra-abdominal [ie, peritoneal, mesenteric, retroperitoneal], primary or secondary tumor(s) or cyst(s), sum of the maximum length of tumor(s) or cyst(s); 5.1-10 cm). A couple of notes: 1) The regional lymph node resection, as it is listed as included instead of with the description as part of the primary procedure, is not required to be performed to meet the definition of a radical nephrectomy. We have seen numerous coders misinterpret the word “includes” when incorporated into a CPT description. The word “includes,” when used in this context for CPT, means that if performed, the service is not allowed to be reported separately if performed during the same operation; however, it does not mean it is required to support the use of the code if the primary procedure is performed, and 2) the use of the 49186-49190 code series is allowed to be reported if the mass is not contiguous or separate from the primary tumor and the tumors removed are summed and reported with the appropriate code from the series instead of reported separately for each code.

• If the final operative note supports that the lymph nodes were removed with the surrounding tissue, it might be appropriate to report only code 50320 with or without modifier -22 based on the total work effort required for the procedure.

As always, we encourage you to communicate among all team members and pay attention to your documentation. Finally, the medical necessity of the service needs to be expressed within the documentation submitted.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.