Leah Posted Sat 21st of February, 2015 10:18:43 AM
Our surgeon titled his op note "Open partial cystectomy, left distal ureterectomy with left pelvic lymph node dissection."
The patient had a distal ureteral tumor, so the surgeon made a wide, extended excision around the ureteral orifice, then made a clean dissection above the tumor margin in the ureter. He then did a ureteral reimplant of the ureter to the superior dome of the bladder, then proceeded with the lymph node dissection.
Would this be more appropriately coded as a ureteral reimplant 50780, or as a partial cystectomy as the surgeon titled the procedure, perhaps using 51550 with respect to the location of the tumor and the ureteral reimplant?
For the lymph, I believe 38770 is the correct coding.
Any guidance and explanation is appreciated. Thank you.
SuperCoder Answered Mon 23rd of February, 2015 23:45:49 PM
The provider does not seems to be removing the partial bladder as explained by the description above.
Code 50650, Ureterectomy, with bladder cuff (separate procedure) would be more appropriate for above scenario.
38770 is correct code for pelvic lymph node dissection.