Karen Posted Tue 03rd of March, 2020 18:51:50 PM
One of our patients is requiring a radical cystoprostatectomy, bilateral total lymphadenectomy w/ periaortic lymph nodes, and open ileal conduit for invasive bladder cancer. His insurance, however, is stating they will only cover CPT 51597 pelvic exenteration, complete, for vesical, prostatic or ureteral malignancy, with removal bladder and ureteral transplantations, with or without hysterectomy and/or abdomenoperineal resection of rectum and colon or colostomy, OR ANY COMBINATION THEREOF. I'm thinking because of the last phrase "or any combination thereof", the insurance believes it is the same as the 4 codes my doctor is going to perform. Does some part of the intestinal tract or rectum need to be removed to "qualify" for 51597? I need to know how to argue that pelvic exenteration is NOT what the doctor is planning. Thank you for your assistance!
SuperCoder Answered Wed 04th of March, 2020 08:04:42 AM
Thanks for your question.
To qualify for code 51597 the provider explores the abdomen by making a low midline incision in the lower abdomen. He first clamps the blood vessels and removes the bladder, urethra, lower ureters, lymph nodes, and ureters. He next may remove the reproductive organs, the prostate in men, and the uterus and ovaries in females if necessary, along with the rectum and colon depending upon the spread of the tumor.
If the provider removes the rectum and bladder, he creates two openings, or stomas on the abdominal wall for collecting bowel through creation of a colostomy, and urine by transplantation of the ureters to the abdomen wall. Once the provider completes removal of the necessary pelvic organs, he closes the abdominal wound by suturing the layers of tissue together.
The codes (51999, 55866, and 38572) you are suggesting are laparoscopy procedures. Therefore, the procedure note should explain the usage of laparoscopy for the procedure performed.