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Urology/2nd Nephrectomy

Cherie Posted Mon 29th of February, 2016 10:01:06 AM

Our Dr. did a nephrectomy a week ago for the same kidney. (Same Dr)The question is, will this be billable as a complication or considered an error on the surgeons part and not billable. Please read below. Would appreciate your input.
SUMMARY OF PROCEDURE
After induction of general anesthesia and placement of a central line, a
midline incision was made. Bookwalter retractor was placed. All
clotting old blood was evacuated using suction and lap sponges. Once
there was adequate visualization, a retractor was put in place in the
bed of the kidney. It appeared that the upper pole of the kidney was
still intact. At this point, I went ahead and dissected out the upper
pole renal artery and vein and dissected these and divided them with
Endo-GIA stapler. The remainder of the kidney was removed. Initially
in the previous surgery 1 week ago it seemed that the radical
nephrectomy was performed, but clearly due to the small and atrophic
nature the kidney, a stapler was fired across the upper pole of the
kidney, and some of the kidney remained. This was the source of
bleeding. At this point there was excellent hemostasis. There was

SuperCoder Answered Tue 01st of March, 2016 01:24:43 AM

Hi,

The procedure which doctor described sound little confusing as in the previous surgery as per documents radical nephrectomy was performed with only pole left. Also, in the current surgery doctor is stating he removed the pole along with remainder of the kidney.
All we can suggest is that for the previous surgery one should use the modifier 52.

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