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Would this really be a partial nephrectomy? Physician is wants to code as such.

Nancy Posted Tue 02nd of December, 2014 18:37:51 PM

The patient was taken to the operating room today for left retroperitoneal robotic caliceal diverticulectomy. There were 2 diverticulum and these were filled with stone material and these were excised completely and fulgurated. There was also peripelvic cyst which was seen on ultrasound which was opened. The communication to the clotting system was closed with a suture. The defect was closed primarily with sliding clip renorrhaphy. A drain was placed.

SuperCoder Answered Fri 05th of December, 2014 03:07:42 AM

Thank you for your question.

You should report this procedure using CPT code 50549-RT (Unlisted laparoscopy procedure, renal). There are CPT codes for example: 52346 and 52352 that merely approximates the service provided. However, there is no specific code available for the retroperitoneal robotic caliceal diverticulectomy procedure performed.
Documentation indicate that peripelvic cyst which was seen on ultrasound. Ultrasound would be coded separately. However, the documentation do not clearly indicate the exact mode of ultrasound and the extent of structures scanned. You may refer to the following code range: 76770-76775. Also, to report the ultrasound code separately please provide detailed description if the ultrasound was performed intraoperatively or not.

Thank you!

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