Coding Q&A: Billing for female total urethrectomy with complete cystectomy

I have a question about female total urethrectomy with complete cystectomy. If the physician performs a total urethrectomy (CPT code 53210) on a female patient at the same time as a complete cystectomy with ureteroileal conduit (code 51590), it is separately billable. But if the total urethrectomy is performed with a complete cystectomy with ureteroileal conduit with bilateral pelvic lymph node dissection (code 51595), it is bundled and not separately billable. Why is this?

Jonathan Rubenstein, MD

To best answer this question, let’s look at the CPT codes that may be applicable to this situation, along with their descriptors:

• CPT 53210: Urethrectomy, total, including cystostomy; female

• CPT 51590: Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis

• CPT 51595: Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes

Mark Painter

And now that we have the codes with their descriptors, we need to go deeper into what these codes truly describe. When CPT codes are created and valued, it is the typical procedure that is used. So what are some typical indications for surgical excision of the urethra and bladder? As adult urologists, one obviously thinks about cancer. Yet we need to expand that because there are many benign (noncancerous) reasons to perform these procedures, especially in a younger population.

So when we think about a typical procedure for performing a radical cystectomy for cancer with an ileal conduit, that would typically involve lymph node dissection, and therefore CPT 51595 would be best chosen to report that combined procedure. We can all agree that lymph node dissection is extra work above and beyond the cystectomy and therefore also involves extra value. The National Correct Coding Initiative (NCCI) includes code 53210 with 51595 but is marked as unbundling allowed with an appropriate modifier. This designation would indicate that the urethrectomy is considered to be included under most circumstances but is allowed to be reported and paid with an appropriate modifier. If documentation supports that the urethrectomy was separate and distinct and not part of the work required to complete the cystectomy, it can be separately reported with an appropriate modifier appended (-59 or -XU). Be prepared to submit documentation if reported.

In contrast, bladder removal for benign conditions with a conduit or sigmoid bladder would not typically involve lymph node dissection and the surrounding structures limiting the work required to complete the cystectomy to the bladder; therefore, CPT 51590 would typically be reported. As code 51590 does not require the additional resection of that which is required for code 51595, urethrectomy is typically not performed when removing the bladder for benign conditions. The NCCI apparently agrees, and code 53210 is not included in code CPT 51590. When reporting the cystectomy with code 51590, if the urethrectomy is performed and documented it may be reported separately without a modifier.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.