Coding Companion for Urology/Nephrology A comprehensive illustrated guide to coding and reimbursement
Contents Getting Started with Coding Companion... i Integumentary...1 Arteries and Veins...15 Lymph Nodes...29 Abdomen...36 Kidney...53 Ureter...109 Bladder...146 Urethra...219 Penis...257 Testis...294 Epididymis...309 Tunica Vaginalis...316 Scrotum... 319 Vas Deferens... 324 Spermatic Cord... 329 Seminal Vesicles... 333 Prostate... 336 Reproductive... 350 Intersex Surgery... 351 Vagina... 352 Medicine Services... 362 Appendix... 376 Evaluation and Management... 403 Index... 425 Contents
50040 50040 Nephrostomy, nephrotomy with drainage The physician creates an opening through the kidney to the exterior of the body by making an incision in the kidney. To access the kidney, the physician makes an incision in the skin of the flank, cuts the muscles, fat, and fibrous membranes (fascia) overlying the kidney, and sometimes removes a portion of the eleventh or twelfth rib. Using an incision to open the renal pelvis (pyelotomy), the physician passes a curved clamp into the renal pelvis, a middle or lower minor calyx, and the cortex of the kidney. The physician inserts a catheter tip through the same path as the clamp, and passes the tube through a stab incision in the skin of the flank. After suturing the incisions, the physician inserts a drain tube, bringing it out through a separate stab incision, and performs a layered closure. For nephrostomy, percutaneous, see 50395 or 52334. For pyelotomy with drainage (pyelostomy), see 50125. For percutaneous pyelostomy, see 50392. If the physician changes the nephrostomy tube, see 50398. For endoscopy through the nephrostomy in a later session, see 50551 50562. ICD-9-CM Procedural 55.01 Nephrotomy 55.02 Nephrostomy Anesthesia 50040 00862 ICD-9-CM Diagnostic 588.81 Secondary hyperparathyroidism (of renal origin) 588.89 Other specified disorders resulting from impaired renal function 590.10 Acute pyelonephritis without lesion of renal medullary necrosis (Use 590.11 Acute pyelonephritis with lesion of renal medullary necrosis (Use 590.2 590.3 Renal and perinephric abscess (Use Pyeloureteritis cystica (Use 590.80 Unspecified pyelonephritis (Use 592.0 593.2 593.4 Calculus of kidney Acquired cyst of kidney Other ureteric obstruction 593.70 Vesicoureteral reflux, unspecified or without reflex nephropathy 593.89 Other specified disorder of kidney and ureter 599.70 Hematuria, unspecified 599.71 Gross hematuria 599.72 Microscopic hematuria 753.11 Congenital single renal cyst 753.13 Congenital polycystic kidney, autosomal dominant 753.14 Congenital polycystic kidney, autosomal recessive 753.15 Congenital renal dysplasia 753.16 Congenital medullary cystic kidney 753.17 Congenital medullary sponge kidney 753.19 Other specified congenital cystic kidney disease 753.20 Unspecified obstructive defect of renal pelvis and ureter 753.21 Congenital obstruction of ureteropelvic junction 753.22 Congenital obstruction of ureterovesical junction 753.23 Congenital ureterocele 753.29 Other obstructive defect of renal pelvis and ureter 866.01 Kidney hematoma without rupture of capsule or mention of open wound into cavity 958.5 Traumatic anuria Terms To Know calculus. Abnormal, stone-like concretion of calcium, cholesterol, mineral salts, or other substances that forms in any part of the body. catheter. Flexible tube inserted into an area of the body for introducing or withdrawing fluid. congenital. Present at birth, occurring through heredity or an influence during gestation up to the moment of birth. hematoma. Tumor-like collection of blood in some part of the body caused by a break in a blood vessel wall, usually as a result of trauma. nephrostomy. Placement of a stent, tube, or catheter that forms a passage from the exterior of the body into the renal pelvis or calyx, often for drainage of urine or an abscess, for exploration, or calculus extraction. pyelonephritis. Infection of the renal pelvis and ureters that may be acute or chronic, often occurring as a result of a urinary tract infection, particularly in instances of vesicoureteric reflux, the backflow of urine from the bladder into the kidney pelvis or ureters. ureterocele. Saccular formation of the lower part of the ureter, protruding into the bladder. CCI Version 14.3 36000, 36410, 37202, 44950, 49000-49010, 50010-50020, 50045v, 50500, 50541, 51701-51703, 62318-62319, 64415-64417, 64450, 64470, 64475, 69990, 90760, 90765, 90772, 90774, 90775 Note: These CCI edits are used for Medicare. Other payers may reimburse on codes listed above. Medicare Edits Fac Non-Fac RVU RVU FUD 50040 26.34 26.34 90 Medicare References: None Assist N/A Kidney Kidney 55
Appendix 0084T 0084T Insertion of a temporary prostatic urethral stent A physician inserts a temporary urethral stent in a patient with prostatic urethral obstruction to improve voiding function. The stent system consists of a proximal balloon to prevent distal displacement, a urine port situated above to the balloon, and the stent. Topical anesthesia is administered and the physician inserts the probe to locate the external sphincter. Once the external sphincter is located, a measurement is taken and the proper size stent selected. The stent device is mounted on a single-use insertion tool and standard catheter insertion technique is used to insert it. The proximal tip, balloon, and urine port are positioned in the bladder and the balloon is inflated with 5 cc of water. The insertion device is removed. A distal anchor mechanism is secured by sutures. A retrieval suture that extends to the meatus and deflates the balloon when pulled is also secured. The stent is typically left in place for up to 90 days. 0087T 0087T Sperm evaluation, Hyaluronan sperm binding test Hyaluronan or hyaluronic acid binding (HAB) is a qualitative assay to determine sperm maturity in a fresh semen sample. Low levels of sperm binding to hyaluronan indicate that there is a low proportion of mature sperm capable of penetrating an ova and that there is a need for an intracytoplasmic sperm injection procedure (ICSI), an assisted reproductive technique. 0141T-0142T 0141T Pancreatic islet cell transplantation through portal vein, percutaneous 0142T Pancreatic islet cell transplantation through portal vein, open Islet cells are insulin-producing cell clusters found only in the pancreas. In islet cell transplants, insulin-producing islet cells are infused into the liver by portal vein embolization. Islet cell transplant is considered a less invasive alternative to pancreatic transplant. The physician uses ultrasonic guidance to insert a catheter through a skin incision in the upper abdomen and into the portal vein of the liver. Islet cells are slowly infused through the catheter. The pressure within the portal vein is monitored during the procedure to ensure that the vessel is not occluded. The catheter is removed and the incision closed. The islet cells will attach to the vessel walls in the portal vein and begin releasing insulin within a month. This procedure is limited to persons with type 1 diabetes. In an open procedure,0142t, the surgeon makes an incision in the skin overlying the liver and inserts a catheter into the portal vein. 0143T 0143T Laparoscopy, surgical, pancreatic islet cell transplantation through portal vein Islet cells are insulin-producing cell clusters found only in the pancreas. In islet cell transplants, insulin-producing islet cells are infused into the liver by portal vein embolization. Islet cell transplant is considered a less invasive alternative to pancreatic transplant. The physician places a laparoscope via a small periumbilical port or through a small incision in the right upper quadrant, and an additional port is placed in the right upper quadrant under direct vision. The physician inserts a catheter into the portal vein of the liver. Islet cells are slowly infused through the catheter. The pressure within the portal vein is monitored during the procedure to ensure that the vessel is not occluded. The catheter is removed along with the laparoscope tools, and the incision closed. The islet cells will attach to the vessel walls in the portal vein and begin releasing insulin within a month. This procedure is limited to persons with type 1 diabetes. 0193T 0193T Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence The physician uses radiofrequency energy to treat female stress urinary incontinence, the involuntary loss of urine from the urethra due to increased intra-abdominal pressure. Using a small transurethral probe, the physician applies low temperature radiofrequency energy to targeted submucosal areas of the bladder neck and urethra. This results in minute structural alterations to the collagen which, upon healing, make the tissues firmer and increase their resistance to involuntary leakage. This code is new for 2009. 74000 74000 Radiologic examination, abdomen; single anteroposterior view Films are taken of the abdominal cavity in one view from front to back. Because an abdominal x-ray usually precedes another diagnostic imaging procedure, it is not coded separately unless performed as a separately identifiable examination. 74010 74010 Radiologic examination, abdomen; anteroposterior and additional oblique and cone views Films are taken of the abdominal cavity from front to back, with an oblique view and a focused (coned down or spot) view. Because an abdominal x-ray usually precedes another diagnostic imaging procedure, it is not coded separately unless performed as a separately identifiable examination. 74020 74020 Radiologic examination, abdomen; complete, including decubitus and/or erect views Films are taken of the abdominal cavity from front to back, back to front, or front to back with the patient lying on the side and/or standing. Because an abdominal x-ray usually precedes another diagnostic imaging procedure, it is not coded separately unless performed as a separately identifiable examination. 74022 74022 Radiologic examination, abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest Films are taken of the abdominal cavity with the patient lying flat, standing, and/or lying on the side. This procedure includes an upright chest x-ray. Because an abdominal x-ray usually precedes another diagnostic imaging procedure, it is not coded separately unless performed as a separately identifiable examination. 74150-74170 74150 Computed tomography, abdomen; without contrast material 74160 with contrast material(s) 74170 without contrast material, followed by contrast material(s) and further sections Computed tomography directs multiple thin beams of x-rays at the body structure being studied and uses computer imaging to produce thin cross-sectional views of various layers (or slices) of the body. It is useful for the evaluation of trauma, tumor, and foreign bodies as CT is able to visualize soft tissue as well as bones. Patients are required to remain motionless during the study and sedation may need to be administered as well as a contrast medium for image enhancement. These codes 376 Appendix
of less than 15 minutes. Code 96376 may be reported only by facilities. These codes are new for 2009. They replace 90772 90776 that have been deleted. 98960-98962 98960 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient 98961 2-4 patients 98962 5-8 patients The qualified, nonphysician health care professional provides education and training using a standard curriculum. This training is prescribed by a physician to enable the patient to concurrently self-manage established illnesses or diseases with health care providers. Report 98960 for education and training provided for an individual patient for each 30 minutes of service. Report 98961 for a group of two to four patients and 98962 for a group of five to eight patients. 99026-99027 99026 Hospital mandated on call service; in-hospital, each hour 99027 out-of-hospital, each hour The code reports the time for hospital mandated on call service provided by the physician. This code does not include prolonged physician attendance time for standby services or the time spent performing other reportable procedures or services. Report 99026 for each hour of hospital mandated on call service spent in the hospital and 99027 for each hour of hospital mandated on call service spent outside the hospital. 99051 99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service provided during posted evening, weekend, or holiday office hours in addition to basic services. 99053 99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service provided between 10 p.m. and 8 a.m. at a 24-hour facility in addition to basic services. 99060 99060 Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service provided on an emergency basis in a location other than the physician's office that disrupt other scheduled office services. 99507 99507 Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral) The home health provider visits the patient at home for care and maintenance of catheter, such as urinary catheters, and catheters placed for drainage or enteral feeding. Skilled procedures required for the home visit include Foley catheter and suprapubic catheter insertion and management; gastrostomy tube/catheter maintenance and enteral feeding; dressing changes and assessment of catheter-related wounds; management of open or draining wounds, ulcers, or fistulae and drainage tube/catheter management; related suture/staple removal; and urinary incontinence catheter management. Appendix Appendix 401