Sample page. Urology/Nephrology. A comprehensive illustrated guide to coding and reimbursement CODING COMPANION

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1 CODING COMPNION 2018 Urology/Nephrology comprehensive illustrated guide to coding and reimbursement POWER UP YOUR CODING with Optum360, your trusted coding partner for 32 years. Visit optum360coding.com.

2 Contents Getting Started with Coding Companion...i Integumentary... 1 rteries and Veins Lymph Nodes bdomen...49 Kidney Ureter Bladder Urethra Penis Testis Epididymis Tunica Vaginalis Scrotum Vas Deferens Spermatic Cord Seminal Vesicles Prostate Reproductive Intersex Surgery Vagina Medicine Services HCPCS ppendix Correct Coding Initiative Update Evaluation and Management Index CPT 2017 merican Medical ssociation. ll Rights Reserved. Contents i

3 Fine needle aspiration; without imaging guidance with imaging guidance Fine needle aspiration (FN) is a percutaneous procedure that uses a fine gauge needle (often 22 or 25 gauge) and a syringe to sample fluid from a cyst or remove clusters of cells from a solid mass. First, the skin is cleansed. If a lump can be felt, the radiologist or surgeon guides a needle into the area by palpating the lump. If the lump is non-palpable, the FN procedure is performed under image guidance using fluoroscopy, ultrasound, or computed tomography (CT), with the patient positioned according to the area of concern. In fluoroscopic guidance, intermittent fluoroscopy guides the advancement of the needle. Ultrasonography-guided aspiration biopsy involves inserting an aspiration catheter needle device through the accessory channel port of the echoendoscope; the needle is placed into the area to be sampled under endoscopic ultrasonographic guidance. fter the needle is placed into the region of the lesion, a vacuum is created and multiple in and out needle motions are performed. Several needle insertions are usually required to ensure that an adequate tissue sample is taken. CT image guidance allows computer-assisted targeting of the area to be sampled. t the completion of the procedure, the needle is withdrawn and a small bandage is placed over the area. Report if fine needle aspiration is performed without imaging guidance. Report if imaging guidance is used to assist in locating the lump. When or is performed with another separately identifiable procedure, the highest dollar value code is listed as the primary procedure and subsequent procedures are appended with modifier 51. If multiple areas are aspirated, report or for each site taken and append modifier 59 or an X{EPSU} modifier to additional codes. For evaluation of fine needle aspirate, see For radiological supervision and interpretation, see 76942, 77002, 77012, and For percutaneous needle biopsy, abdominal or retroperitoneal mass, see 49180; kidney, see 50200; testis, see and epididymis, see For percutaneous image-guided fluid collection drainage of soft tissue via catheter, see Tuberculosis of prostate Diphtheritic polyneuritis Diphtheritic tubulo-interstitial nephropathy C61 Malignant neoplasm of prostate C63.01 Malignant neoplasm of right epididymis C63.02 Malignant neoplasm of left epididymis C64.1 Malignant neoplasm of right kidney, except renal pelvis C64.2 Malignant neoplasm of left kidney, except renal pelvis C65.1 Malignant neoplasm of right renal pelvis C65.2 Malignant neoplasm of left renal pelvis C76.2 Malignant neoplasm of abdomen C79.01 Secondary malignant neoplasm of right kidney and renal pelvis C79.02 Secondary malignant neoplasm of left kidney and renal pelvis C79.82 Secondary malignant neoplasm of genital organs D29.1 Benign neoplasm of prostate D29.31 Benign neoplasm of right epididymis D29.32 Benign neoplasm of left epididymis D30.01 Benign neoplasm of right kidney D30.02 Benign neoplasm of left kidney D30.11 Benign neoplasm of right renal pelvis D30.12 Benign neoplasm of left renal pelvis N00.0 cute nephritic syndrome with minor glomerular abnormality N00.1 N00.2 N00.3 N00.4 N00.5 N00.6 N00.7 N00.8 N02.0 N03.2 N03.4 N03.5 N03.6 N03.7 N03.8 N04.0 N04.4 N40.0 N40.1 cute nephritic syndrome with focal and segmental glomerular lesions cute nephritic syndrome with diffuse membranous cute nephritic syndrome with diffuse mesangial proliferative cute nephritic syndrome with diffuse endocapillary proliferative cute nephritic syndrome with diffuse mesangiocapillary cute nephritic syndrome with dense deposit disease cute nephritic syndrome with diffuse crescentic cute nephritic syndrome with other morphologic changes Recurrent and persistent hematuria with minor glomerular abnormality Chronic nephritic syndrome with diffuse membranous Chronic nephritic syndrome with diffuse endocapillary proliferative Chronic nephritic syndrome with diffuse mesangiocapillary Chronic nephritic syndrome with dense deposit disease Chronic nephritic syndrome with diffuse crescentic Chronic nephritic syndrome with other morphologic changes Nephrotic syndrome with minor glomerular abnormality Nephrotic syndrome with diffuse endocapillary proliferative Benign prostatic hyperplasia without lower urinary tract symptoms Benign prostatic hyperplasia with lower urinary tract symptoms Integumentary CPT 2017 merican Medical ssociation. ll Rights Reserved. Integumentary 1

4 Kidney Excision or unroofing of cyst(s) of kidney Excision of perinephric cyst The physician excises a cyst on the kidney or in the surrounding renal tissue. To access the kidney, the physician makes an incision in the skin of the flank, cuts the muscles, fat, and fibrous membranes (fascia) overlying the kidney, and sometimes removes a portion of the twelfth rib. fter clearing away the fatty tissue surrounding the kidney, the physician excises the cyst from the renal surface. The physician destroys tiny vessels bordering the cyst with high-frequency electric current (fulguration) to minimize the need for sutures. If the cyst requires a deep excision, the physician usually sutures the renal tissue. The physician inserts a drain tube, bringing it out through a separate stab incision in the skin, and performs a layered closure reports excision of a cyst (or cysts) on the kidney; reports excision of a cyst (or cysts) in the tissue surrounding the kidney. For laparoscopic ablation of renal cysts, see N28.1 N28.89 Q61.01 Q61.02 Q61.11 Q61.19 Q61.2 Q61.8 Cyst of kidney, acquired Other specified disorders of kidney and ureter Congenital single renal cyst Congenital multiple renal cysts Cystic dilatation of collecting ducts Other polycystic kidney, infantile type Polycystic kidney, adult type Other cystic kidney diseases HCPCS Equivalent Codes Terms To Know acquired. Produced by outside influences and not by genetics or birth defect. congenital. Present at birth, occurring through heredity or an influence during gestation up to the moment of birth. cyst. Elevated encapsulated mass containing fluid, semisolid, or solid material with a membranous lining. excision. Surgical removal of an organ or tissue. fulguration. Destruction of living tissue by using sparks from a high-frequency electric current. polycystic. Multiple cysts. suture. Numerous stitching techniques employed in wound closure. buried suture. Continuous or interrupted suture placed under the skin for a layered closure. continuous suture. Running stitch with tension evenly distributed across a single strand to provide a leakproof closure line. interrupted suture. Series of single stitches with tension isolated at each stitch, in which all stitches are not affected if one becomes loose, and the isolated sutures cannot act as a wick to transport an infection. purse-string suture. Continuous suture placed around a tubular structure and tightened, to reduce or close the lumen. retention suture. Secondary stitching that bridges the primary suture, providing support for the primary repair; a plastic or rubber bolster may be placed over the primary repair and under the retention sutures. Medicare Edits Fac RVU * with documentation Non-Fac RVU Modifiers 62* 62* FUD Status MUE 1(2) Medicare Reference None CPT 2017 merican Medical ssociation. ll Rights Reserved. 92 Kidney

5 Medicine Services Hemodialysis procedure with single evaluation by a physician or other qualified health care professional Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription Hemodialysis is a process to remove toxins from the blood and to maintain fluid and electrolyte balance when the kidneys no longer function. The procedure involves using a previously placed catheter in an artery or a vein to withdraw the patient's blood, mechanically circulating the blood through a dialysis machine to remove the toxins and wastes, and transfusing the blood back to the patient. Code applies to one hemodialysis treatment that includes a single physician or other qualified health care provider's evaluation of the patient and is for a hemodialysis procedure when patient re-evaluation(s) must be done during the procedure, with or without substantial revision of the dialysis prescription. For prolonged physician or other qualified health care provider attendance, see I12.0 I13.0 I13.11 I13.2 I16.0 I16.1 N17.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease Hypertensive urgency Hypertensive emergency cute kidney failure with tubular necrosis N17.1 N17.2 N17.8 N18.4 N18.5 N18.6 Z49.31 cute kidney failure with acute cortical necrosis cute kidney failure with medullary necrosis Other acute kidney failure Chronic kidney disease, stage 4 (severe) Chronic kidney disease, stage 5 End stage renal disease Encounter for adequacy testing for hemodialysis HCPCS Equivalent Codes Terms To Know cannula. Tube inserted into a blood vessel, duct, or body cavity to facilitate passage. catheter. Flexible tube inserted into an area of the body for introducing or withdrawing fluid. chronic kidney disease. Decreased renal efficiencies resulting in reduced ability of the kidney to filter waste. The National Kidney Foundation's classification includes five clinical stages, based on the glomerular filtration rate (GFR). The stages of CKD are as follows: stage 1, some kidney damage with normal or slightly increased GFR (> 90); stage 2, mild kidney damage with a GFR value of 60 to 89; stage 3, moderate kidney damage with a GFR value of 30 to 59; stage 4, severe kidney damage and a GFR value of 15 to 29; and stage 5, severe kidney damage that has progressed to a GFR value of less than 15. Dialysis or transplantation is required at stage 5. ESRD. End stage renal disease. Progression of chronic renal failure to lasting and irreparable kidney damage that requires dialysis or renal transplant for survival. hemodialysis. Cleansing of wastes and contaminating elements from the blood by virtue of different diffusion rates through a semipermeable membrane, which separates blood from a filtration solution that diffuses other elements out of the blood. qualified health care professional. Educated, licensed or certified, and regulated professional operating under a specified scope of practice to provide patient services that are separate and distinct from other clinical staff. Medicare Edits Fac RVU Non-Fac RVU Modifiers * with documentation 80* 80* FUD 0 0 Status MUE Medicare Reference ,1,10; ,11,20; ,130.8; ,3,100.6; ,4, Medicine Services CPT 2017 merican Medical ssociation. ll Rights Reserved.