Urology

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 AMA manual’s CPT codes

Level II 88302

Foreskin Newborn;   Hydrocelle Sac;    Testis, Castration;      Vas Deferens, Sterilization

No any coding difficulties.

Level III 88304

Foreskin, Other than Newborn;   Spermatocele;   Testicular Appendage;   Varicocele;

Vas Deferens, Other than Sterilization.

Only spermatocelle might be a reason for considerations if the procedure were made correctly when the content of the spermatocelle would be examined for presence of spermatozoids with appropriate microscopic examination but the code remains the same anyway in this situation.

Level IV 88305

Kidney biopsy in urology is different from kidney biopsy in nephrology by absence of ancillary studies for immunofluorescence and electron microscopy.

Prostate, Needle biopsy should be distinguished from prostate saturation needle biopsy that has four codes HCPCS GO416-GO 419 depending on the amount of cores but not containers. These codes were added for Medicare billing. They cannot be reported with a traditional region approach needle biopsy.

Prostate, TUR – actually “chips” of prostate tissue after transuretal resection can be few or voluminous as to 40 -50 grams with numerous blocks, but always remains at Level 88305.

The rest are unremarkable.

Testis, Other than Tumor/Biopsy/castration;     Ureter, Biopsy;     Urethra, Biopsy;       

Urinary Bladder,

Level V 88307

Kidney, Partial/Total Nephrectomy

                         Prostate, Except Radical Resection (Case #4 –E)

Testis, Biopsy (one of rare occasions when a biopsy is Level V 88307)

Ureter Resection (sometimes the requisition form does not mention the word resection and the specimen is accessioned as a biopsy, especially in pediatric urology). Case # 3-M, N)

Urinary Bladder TUR transuretal resection of the bladder is made in a tumor case and can be confused with prostate TUR if scarce material is sent to pathology.

Adrenal, Resection (the gland can be submitted with (more often) or without nephrectomy, as well as a separately in a case of tumor or trauma).

Level VI 88309

Prostate, Radical Resection, (Cases ## 1-B and 2)           Testis, Tumor;          Urinary Bladder/Total Resection (Cases ## 3- J and 4)

Suggested codes for unlisted in CPT Manual specimens in urology practice in alphabetic order. The list includes also diagnoses or surgical procedures that appear in the requisition forms instead of specimen’s description.

 

Descriptor /code Comment
Adrenal gland, Resection/88307Chips (TUR) bladder/88307Chips (TUR) prostate/88305Circumcision newborn/88302Circumcision  Other than Newborn/88304

Cystectomy- partial or   total bladder resection/88309

Epididymis/88304

Fistula/88304

Penis amputation – partial   or complete/88307

Penis biopsy/88305

Penis resection for tumor/88309

Renal biopsy/88305

Seminal vesicle/88304

Surgical margin/88305

Urinary bladder neck   (margin)/88305

till 1 year old 

 

 

bladder

Prostate and urinary bladder are not difficult for CPT coding, although there are some particularities that complicates the right interpretation of coding rules. The main source of controversy is lymph node coding, as well as sometimes the obligatory specimen bundling provisions.

The following case scenarios can show that coding can be different depending on formulation words in the requisition form. The considerations presented in Lymph Node Coding section become more illustrated.

Case #1    Confusing lymph nodes description

A 54-year-old man underwent prostatectomy due to prostatic adenocarcinoma, Gleason’s score (3+3), involving the right and left lobes after positive for carcinoma needle biopsy. The operation was described as radical retropubic prostatectomy, bilateral lymph node dissections.

Accession

 

S/# Specimen description CPT code
A Left pelvic node Level V 88307
B Right pelvic node Level V 88307
C Radical prostate Level VI 88309

Final billing code after the pathologist’s report

S/# Specimen description CPT code
A Left pelvic lymph nodes   biopsy, two lymph nodes, negative for carcinoma Level V 88307
B Right pelvic lymph node   biopsy- one lymph node , negative for carcinoma Level IV 88305
C Radical prostatectomy,   moderately differentiated adenocarcinoma involving the right and left lobes,   tumor focally seen at the left bladder neck margin seminal vesicle negative   for carcinoma Level VI 88309

First, the clinician should specify in the requisition form the procedure as biopsy or regional resection. Second, the pathologist qualified the procedure as biopsy despite the operation was defied as lymph node dissection. Third, the billing manager changed the accession coding in specimen B for Level IV 88305 as biopsy because only one lymph node was revealed. There is not any difference in the nature of the procedure. This is an illustration of the arithmetical approach that is wide spread in practice. However, if the local coding practice uses this policy, that is the way of consistency until the coding authorities issue a specific regulatory document.

 

Case #2 Lymph Nodes Regional Resection

A 61-year-old man underwent radical prostatectomy due to adenocarcinoma on the needle biopsy. The surgery is defined as radical prostatectomy with bilateral lymph node excision.

Accession

 

S/# Specimen description CPT code
A Left external iliac &   obturator lymph nodes Level V 88307
B Right external iliac &   obturator lymph nodes Level V 88307
C Bladder neck margin Level IV 88305
D Prostate Level VI 88309

 

Final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A Left external&obturator   lymph nodes, excision-One benign lymph node, negative for malignancy Level V 88307
B Right external iliac &   obturator lymph nodes, excision- Three benign lymph nodes, negative for   malignancy Level V 88307
C Bladder neck margin   –fibromuscular tissue, negative for malignancy Level IV 88305
D Prostate, radical   prostatectomy, moderately differentiated adenocarcinoma, apex, neck, seminal   vesicles and vas deferens resection margin free of tumor Level VI 88309

In the case # 2 no changes have been made. The difference is only in formulation of the same procedure. It does not matter how it is called in the requisition form as pelvic node packet, or external & obturator nodes excision (case #2), or pelvic nodes biopsy (case #1). In essence this is Level V Lymph Nodes, Regional Resection. It does not matter how many nodes were revealed and do they have malignancy or not. This is a treatment procedure that has also a diagnostic purpose. Procedural approach is in the background of Current Procedural Terminology (CPT).

Case #3 Prostate, Bladder disbundling, Ureter biopsy, again Lymph nodes

A 68-year-old man underwent radical cystoprostatectomy due to urothelial carcinoma. The urinary bladder and prostate were removed in one block. Three frozen section were performed. The case contained 14 containers.

Accession

 

S/# Specimen’s description CPT code
A-C Frozen section- right &   left distal ureter, urethral margin 88331 x 3; 88305 x 3
D Left common iliac lymph   node Level V 88307
E Right common iliac lymph   node Level V 88307
F Right lymph node of cloquet Level V 88307
G Right obturator packet Level V 88307
H Left external lymph node   & left lymph node of cloquet Level V 88307
I Left obturator packet Level V 88307
J Bladder & prostate Level VI 88309
K Right presciatic lymph node Level V 88307
L Left presciatic lymph node Level V 88307
M-N Left & right proximal   ureter Level V 88307

The final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A- C Frozen section-right &   left distal ureter, urethral marginNegative for malignancy 88331 x 388305 x 3
D Left common iliac lymph   node-  Five lymph nodes, negative for   malignancy Level V 88307
E Right common iliac lymph   node- Seven lymph nodes, negative for malignancy Level V 88307
F Right lymph node of   cloquet- One lymph node, positive for metastatic Level V 88307
G Right obturator packet- one   of nine lymph nodes, positive for metastatic urothelial carcinoma Level V 88307
H Left external lymph node   & left lymph node of cloquet-Seven lymph nodes , negative for malignancy Level V 88307
I Left obturator packet-Seven   lymph nodes, negative for malignancy Level V 88307
J Bladder & prostate-   Radical cystoprostatectomy, high-grade urothelial carcinoma, Grade III/III   extensively invading the prostate and seminal vesicles Level VI 8830988342Level VI 88309
K Right presciatic lymph node   – Fibroadipose tissue and connective tissue , negative for malignancy Level V 88307
L Left presciatic lymph   node-Fibroadipose and connective tissue, negative for malignancy Level V 88307
M- N Left proximal ureter-   tubular structure 0.3×0.2×0.2 cm, negative for malignancy Right proximal   ureter- tubular structure 0.7×0.2×0.2 cm, negative for malignancy Level IV x 2 88305 x 2

Bladder and prostate (specimen J) were bundgled correctly in radical cystoprostatectomy that can be included in the computer dictionary or corrected after pathologist’s report by the billing manager.  Both proximal ureter specimens (M&N) are diagnostic biopsies that had been corrected by billing manager. Despite in F only one lymph node was found  and in K & L only fibroadipose tissue was examined, by essence the surgery was regional resection, as it was discussed before.

In a case of a woman when bladder cancer develops, exenteration surgery often is performed with uterus, bilateral tubes and ovaries are removed in one block with the urinary bladder and submitted in the same container. In this situation, the uterus should be unbundled and two codes are assigned: Level VI 88309 for bladder and Level V 88307 Uterus, with or without Tubes and Ovaries, Other than Neoplastic/Prolapse (more often) or Level VI 88309 depending on pathologist’s findings.

Case #4 Bladder radical excision, prostate resection

A 77-year-old man underwent cystectomy with frozen section on margins of resection and excision of the bilateral obturator lymph node packets.

Accession

 

S/# Specimen description CPT code
A – B Frozen sections right &   left distal ureter 88331 x 2; Level IV 88305 x   2
C & D Right & Left obturator   lymph node packet Level V 88307 x 2
E Bladder and superior   prostate Level VI 88309
F Appendix Level III 88304

The lymph nodes had been taken out in two packets that is regional lymph nodes resection by the essence of the procedure (bilateral pelvic lymph node dissection in clinical terms). The last coding situation is now the most frequent because the pathology report’s Staging Summary includes Regional lymph nodes (metastasis/total) definition

The final billing code after the pathologist’s report

 

S/# Specimen description CPT code
A , B Frozen section right &   left distal ureter –negative for malignancy 88331 x 2Level IV 88305 x 2
C , D Right & Left obturator   lymph node packet- two lymph nodes, negative for malignancy Level V 88307
E Bladder and superior   prostate- High-grade urothelial carcinoma, Grade III/III Prostatic tissue   attached to the bladder Level VI 88309Level V88307
F Appendix with focal   lymphoid hyperplasia Level III 88304

In this situation, only a part of prostate is removed that constitutes Level V 88307 Prostate Except Radical Resection.

Case #5 Bundling, again Lymph Nodes

A 47-year-old man underwent radical prostatectomy. Two frozen section were performed for margins of resection. Six specimens (2 + 4) were received.

Accession

Lymph nodes were accessioned according to the specimen descriptions in the requisition forms.

 

S/# Specimen description CPT code
A, B Frozen sections- Left &   Right bladder neck margin 88331Level IV88305
C Right pelvic lymph node   biopsy Level IV88305
D Right pelvic nodes excision Level V88307
E Left pelvic nodes excision Level V88307
F Left seminal vesicle Level III88304
G Prostate Level VI88309

The final fee code after pathologist’s report

 

S/# Specimen description CPT code
A, B Frozen sections- Left &   Right bladder neck margin- Benign adipose tissue and stroma 88331Level IV88305
C Right pelvic lymph node   biopsy – one lymph node 2.9×1.8×1.0 cm with minimal attached adipose tissue,   no evidence of malignancy Level IV88305
D Right pelvic nodes excision   – fibroadipose tissue 4.0×3.0x1.0 cm, One benign lymph node, no evidence of   malignancy Level V88307
E Left pelvic nodes excision   – fibroadipose tissue 4.5x 2.5×1.5 cm, Four benign lymph nodes, no evidence   of malignancy Level V88307
F, G Prostate- Radical   prostatectomy- moderately to poorly differentiated adenocarcinoma, Gleason’s   score 7 (3+4) involving approximately 45% of prostate tissue. Margins free.   The right seminal vesicle 2.0×1.0x0.5 cm, the left seminal vesicle is not   identified. Left seminal vesicle – a fragment of a seminal vesicle   0.9×0.3×0.3 cm no tumor seen Level VI88309

The specimen C was intentionally separate by the surgeon from the specimen D. This is a lymph node biopsy, especially when specimens D and F were defined as excision that is equivalent to CPT descriptor Lymph Nodes, Regional Resection. The seminal vesicle was sent in a separate container with a separate requisition form for some reasons. At the accession level it was naturally logged in the computer as a separate filing (surgical number) and coding entity the accession when it is technically impossible due to the computers programs design by “one container” “one specimen” principle. But the pathologist or billing manager bundled specimens F and G formally following the rule. Seminal vesicle does not exist in the CPT manual, but most computer dictionaries include it as Level III 88304 as an extrapolation of Vas Deference, Other than Sterilization.

The urology section is long but urogenital coding encompass many difficult situation which in other subspecialties less apparent. The principle discussed in these sections will be repeatedly encountered in other, especially in the gynecology.

Disclaimer

These materials do not represent official advice of the CAP, AMA, CMS or other governmental institution. The information will not bear any liability for its application and will not prevent any dispute with a third-party payer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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