UCR 208: FAQ - Clot evacuation and fulguration coding; robotic assisted partial nephrectomy and lymph node resection: clarification

August 23, 2024 

Mark, Scott, and Ray talk about two questions that came into the PRS Communities:

1. I have Optum requesting records on all of our clot evac cases where something in the bladder was fulgurated during the same session and after record review we fail the audit.
   Now compliance is very quick to say refund it, stop billing it, its bundled, etc.
   But we know a modifier is allowed so when is it allowed????

   Everything I find online like AAPC says to bill both 52214 and 52001-59 but there is nothing recent and nothing concrete about what is considered distinct. I mean using a clot evacuator is different than using a loop electrode. Below are the Optum rationales.
   So the urologist does a cysto on hematuria work up, and they wind up using an evacuator to remove huge amounts of clot burden. Then use a loop electrode to fulgurate some areas that look suspicious.
   Why is that service not considered distinct? Compliance says its incidental but they can't tell me when it wouldn't be incidental and I don't want to let optum take back money without an argument.

2. Hi, I would like to ask a coding question please. Thank you so much!

   For Robot-assisted left partial nephrectomy and Resection of a left renal hilar lymph node, Do we code any additional CPT to capture renal hilar lymph node, in addition to partial nephrectomy 50543?

   Pathology report had a separate report for Renal hilar lymph node dissection, which was negative for carcinoma. And for partial nephrectomy, path showed Renal cell carcinoma.