2016 UROLOGY SURGERY
MEDICARE REIMBURSEMENT
CODING GUIDE
Effective January 1, 2016
2016 Medicare Physician, Hospital Outpatient, ASC Coding and Payment
Medicare National Average Rates and Allowables (Not Adjusted for Geography)
PHYSICIAN3
CPT
CODE1/
HCPCS
CODE2
CODE DESCRIPTION
MEDICARE NAT’L AVG
CF=$35.8043
FACILITY
SETTING4
HOSPITAL OUTPATIENT5
APC AND APC
DESCRIPTION
MEDICARE
NAT’L AVG
ASC5
MEDICARE
NAT’L AVG
CYSTECTOMY
51550
Cystectomy, partial; simple
$993
Inpatient only, not reimbursed for
hospital outpatient or ASC
51555
Cystectomy, partial; complicated (eg, postradiation, previous
surgery, difficult location)
$1,306
Inpatient only, not reimbursed for
hospital outpatient or ASC
51565
Cystectomy, partial, with reimplantation of ureter(s) into
bladder (ureteroneocystostomy)
$1,339
Inpatient only, not reimbursed for
hospital outpatient or ASC
51570
Cystectomy, complete (separate procedure)
$1,522
Inpatient only, not reimbursed for
hospital outpatient or ASC
51575
Cystectomy, complete; with bilateral pelvic
lymphadenectomy, including external iliac, hypogastric, and
obturator nodes
$1,878
Inpatient only, not reimbursed for
hospital outpatient or ASC
51580
Cystectomy, complete, with ureterosigmoidostomy or
ureterocutaneous transplantations
$1,952
Inpatient only, not reimbursed for
hospital outpatient or ASC
51585
Cystectomy, complete, with ureterosigmoidostomy or
ureterocutaneous transplantations, with bilateral pelvic
lymphadenectomy, including external iliac, hypogastric, and
obturator nodes
$2,172
Inpatient only, not reimbursed for
hospital outpatient or ASC
51590
Cystectomy, complete, with ureteroileal conduit or sigmoid
bladder, including intestine anastomosis
$1,993
Inpatient only, not reimbursed for
hospital outpatient or ASC
51595
Cystectomy, complete, with ureteroileal conduit or sigmoid
bladder, including intestine anastomosis; with bilateral pelvic
lymphadenectomy, including external iliac, hypogastric, and
obturator nodes
$2,254
Inpatient only, not reimbursed for
hospital outpatient or ASC
51596
Cystectomy, complete, with continent diversion, any open
technique, using any segment of small and/or large intestine
to construct neobladder
$2,422
Inpatient only, not reimbursed for
hospital outpatient or ASC
NEPHRECTOMY
50220
Nephrectomy, including partial ureterectomy, any open
approach including rib resection
$1,079
Inpatient only, not reimbursed for
hospital outpatient or ASC
50225
Nephrectomy, including partial ureterectomy, any open
approach including rib resection; complicated because of
previous surgery on same kidney
$1,240
Inpatient only, not reimbursed for
hospital outpatient or ASC
PHYSICIAN3
CPT
CODE1/
HCPCS
CODE2
CODE DESCRIPTION
MEDICARE NAT’L AVG
CF=$35.8043
FACILITY
SETTING4
HOSPITAL OUTPATIENT5
APC AND APC
DESCRIPTION
MEDICARE
NAT’L AVG
ASC5
MEDICARE
NAT’L AVG
50230
Nephrectomy, including partial ureterectomy, any open
approach including rib resection; radical, with regional
lymphadenectomy and/or vena caval thrombectomy
$1,320
Inpatient only, not reimbursed for
hospital outpatient or ASC
50234
Nephrectomy with total ureterectomy and bladder cuff;
through same incision
$1,339
Inpatient only, not reimbursed for
hospital outpatient or ASC
50236
Nephrectomy with total ureterectomy and bladder cuff;
through separate incision
$1,511
Inpatient only, not reimbursed for
hospital outpatient or ASC
50240
Nephrectomy, partial
$1,363
Inpatient only, not reimbursed for
hospital outpatient or ASC
50543
Laparoscopy, surgical; partial nephrectomy
$1,531
5362, Level 2
Laparoscopy
50545
Laparoscopy, surgical; radical nephrectomy (includes removal
of Gerota's fascia and surrounding fatty tissue, removal of
regional lymph nodes, and adrenalectomy)
$1,380
Inpatient only, not reimbursed for
hospital outpatient or ASC
50546
Laparoscopy, surgical; nephrectomy, including partial
ureterectomy
$1,239
Inpatient only, not reimbursed for
hospital outpatient or ASC
50548
Laparoscopy, surgical; nephrectomy with total ureterectomy
$1,388
Inpatient only, not reimbursed for
hospital outpatient or ASC
$6,861
N/A for
ASC
PROSTATECTOMY
55801
Prostatectomy, perineal, subtotal (including control of
postoperative bleeding, vasectomy, meatotomy, urethral
calibration and/or dilation, and internal urethrotomy)
$1,133
Inpatient only, not reimbursed for
hospital outpatient or ASC
55810
Prostatectomy, perineal radical
$1,359
Inpatient only, not reimbursed for
hospital outpatient or ASC
55812
Prostatectomy, perineal radical; with lymph node biopsy(s)
(limited pelvic lymphadenectomy)
$1,657
Inpatient only, not reimbursed for
hospital outpatient or ASC
55815
Prostatectomy, perineal radical; with bilateral pelvic
lymphadenectomy, including external iliac, hypogastric and
obturator nodes
$1,824
Inpatient only, not reimbursed for
hospital outpatient or ASC
55821
Prostatectomy (including control of postoperative bleeding,
vasectomy, meatotomy, urethral calibration and/or dilation,
and internal urethrotomy); suprapubic, subtotal, 1 or 2 stages
$899
Inpatient only, not reimbursed for
hospital outpatient or ASC
55831
Prostatectomy (including control of postoperative bleeding,
vasectomy, meatotomy, urethral calibration and/or dilation,
and internal urethrotomy); retropubic, subtotal
$973
Inpatient only, not reimbursed for
hospital outpatient or ASC
55840
Prostatectomy, retropubic radical, with or without nerve
sparing
$1,207
Inpatient only, not reimbursed for
hospital outpatient or ASC
55842
Prostatectomy, retropubic radical, with or without
nerve sparing; with lymph node biopsy(s) (limited pelvic
lymphadenectomy)
$1,206
Inpatient only, not reimbursed for
hospital outpatient or ASC
55845
Prostatectomy, retropubic radical, with or without nerve
sparing; with bilateral pelvic lymphadenectomy, including
external iliac, hypogastric, and obturator nodes
$1,405
Inpatient only, not reimbursed for
hospital outpatient or ASC
55866
Laparoscopy, surgical prostatectomy, retropubic radical,
including nerve sparing, includes robotic assistance, when
performed
$1,443
Inpatient only, not reimbursed for
hospital outpatient or ASC
ROBOTIC ASSISTANCE6
S2900
Surgical techniques requiring use of robotic surgical system
(list separately in addition to code for primary procedure)
N/A
NOTES:
1. CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee
schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/
DFARS restrictions apply to government use.
2. Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System. http://www.cms.gov/Medicare/Coding/
HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.
3. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016
Final Rule; 80 Fed. Reg. 70885-71386: http://www.gpo.gov/fdsys/pkg/FR-2015-11-16/pdf/2015-28005.pdf. Published November 16, 2015. See also the
January 2016 release of the PFS Relative Value File RVU16A at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/
PFS-Relative-Value-Files.html. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable
coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.
4. For Medicare, these procedures are payable to the physician in a facility setting but not in the non-facility (office) setting.
5. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment
Systems...Final Rule. 80 Fed. Reg. 70297-70607: http://www.gpo.gov/fdsys/pkg/FR-2015-11-13/pdf/2015-27943.pdf. Published November 13, 2015.
Payment is adjusted by the wage index for each hospital or ASC’s specific geographic locality, so payment will vary from the national average Medicare
payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national
average payment amount shown.
6. HCPCS II S-codes cannot be reported to Medicare. They are used only by non-Medicare payers, which cover and price them according to their own
requirements.
HOSPITAL INPATIENT
PROCEDURE CODING
FOR UROLOGY SURGERY
ICD-10-PCS procedure codes1 are used by hospitals to report surgeries and procedures performed in the inpatient setting.
All ICD-10-PCS codes have seven digits, each digit representing a specific character associated with procedures. Code
assignment in ICD-10-PCS is a process of “constructing” the code by selecting values from a code table for each of the seven
standard characters. Key characters are discussed below.
CHARACTER
DESCRIPTION
The two main root operations for removal of tissue are B-Excision and T-Resection. By definition, B-Excision
involves removing a portion of the body part and T-Resection involves removing the entire body part.2 For
example, partial cystectomy uses B-Excision and complete cystectomy uses T-Resection.
3: Root Operation
Note that physicians may use these terms more broadly. It’s the coder’s responsibility to determine what the
physician’s documentation equates to in terms of ICD-10-PCS definitions. The physician is not expected to
document using ICD-10-PCS code descriptions, and the coder is not required to query the physician in these
circumstances.3
Different codes are constructed depending on the approach:
5: Approach
0-Open involves an open incision to directly expose the surgical site
4-Percutaneous Endoscopic is used for procedures performed via laparoscopy.
ICD-10-PCS PROCEDURE CODE
PROCEDURE CODE DESCRIPTION
CYSTECTOMY
> Partial cystectomy
0TBB0ZZ
Excision of bladder, open approach
0TBB4ZZ
Excision of bladder, percutaneous endoscopic approach
> Total cystectomy
0TTB0ZZ
Resection of bladder, open approach
0TTB4ZZ
Resection of bladder, percutaneous endoscopic approach
> Radical cystectomy
Radical cystectomy involves complete removal of the bladder with diversion of the ureters, sometimes with extensive lymphadenectomy.
Removal of the bladder is coded to total cystectomy, as above. Additional codes are then assigned to capture the ureteral diversion and
lymphadenectomy as performed.
NEPHRECTOMY
> Partial nephrectomy
0TB00ZZ
Excision of right kidney, open approach
0TB04ZZ
Excision of right kidney, percutaneous endoscopic approach
0TB10ZZ
Excision of left kidney, open approach
0TB14ZZ
Excision of left kidney, percutaneous endoscopic approach
> Total nephrectomy
0TT00ZZ
Resection of right kidney, open approach
0TT04ZZ
Resection of right kidney, percutaneous endoscopic approach
0TT10ZZ
Resection of left kidney, open approach
0TT14ZZ
Resection of left kidney, percutaneous endoscopic approach
> Nephroureterectomy
Nephroureterectomy involves complete removal of the kidney with complete removal of the ureter. Removal of the kidney is coded to total
nephrectomy, as above. One or more of the codes below are then assigned additionally to capture the total ureterectomy.
0TT60ZZ
Resection of right ureter, open approach
0TT64ZZ
Resection of right ureter, percutaneous endoscopic approach
0TT70ZZ
Resection of left ureter, open approach
0TT74ZZ
Resection of left ureter, percutaneous endoscopic approach
> Radical nephrectomy
Radical nephrectomy involves complete removal of the kidney, typically with extensive lymphadenectomy and/or removal of the adrenal
gland. Removal of the kidney is coded to total nephrectomy, as above. Additional codes are then assigned additionally to capture the
lymphadenectomy and adrenalectomy as performed.
PROSTATECTOMY
> Excision of prostate lesion, subtotal or partial prostatectomy (suprapubic, retropubic, perineal)
0VB00ZZ
Excision of prostate, open approach
0VB40ZZ
Excision of prostate, percutaneous endoscopic approach
> Total prostatectomy (suprapubic, retropubic, perineal)
0VT00ZZ
Resection of prostate, open approach
0VT04ZZ
Resection of prostate, percutaneous endoscopic approach
ICD-10-PCS PROCEDURE CODE
PROCEDURE CODE DESCRIPTION
> Radical prostatectomy
Radical nephrectomy involves complete removal of the prostate, typically with complete removal of the seminal vesicles, partial removal
of the vas deferens, and/or extensive lymphadenectomy. Removal of the prostate is coded to total prostatectomy, as above. Additional
codes are then assigned to capture removal of the seminal vesicles and vas deferens and the lymphadenectomy as performed.
ROBOTIC ASSISTANCE4
8E0W0CZ
Robotic assisted procedure of trunk region, open approach
8E0W4CZ
Robotic assisted procedure of trunk region, percutaneous endoscopic approach
Notes:
1. ICD-10-CM: Department of Health and Human Services, Centers for Medicare & Medicaid Services. International Classification of Diseases, 10th Revision,
Procedure Coding System (ICD-10-PCS). http://www.cms.hhs.gov/Medicare/Coding/ICD10/2016-ICD-10-PCS-and-GEMs.html
2. CMS ICD-10-PCS Reference Manual 2016, p.38-40. See also ICD-10-PCS Procedure Coding System (ICD-10-PCS) 2016 Tables and Index, ICD-10-PCS
Definitions appendix (0 3: Medical and Surgical - Operation), root operations Excision and Resection
3. 2016 ICD-10-PCS Official Guidelines for Coding and Reporting (Procedure), A11
4. Codes for robotic assistance are assigned separately in addition to the primary procedure code.
HOSPITAL INPATIENT DRGS FOR
UROLOGY SURGERY
DRG Assignment FY2016—effective October 1, 2015
Under Medicare’s MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 750
diagnosis-related groups, based on the ICD-10 codes assigned to the diagnoses and procedures. Each MS-DRG has a relative
weight that is then converted to a flat payment amount. Implanted devices are typically included in the flat payment and are not
paid separately. Only one MS-DRG is assigned for each inpatient stay, regardless of the number of procedures performed. MSDRGs shown are those typically assigned to the following scenarios when the patient is admitted specifically for the procedure.
MSDRG1
MS-DRG TITLE1,2
FY 2016
RELATIVE
WEIGHT1
FY 2016
GEOMETRIC MEAN
LENGTH OF STAY1
FY 2016
SUBJECT TO
PACT?1,3
FY 2016 MEDICARE
NATIONAL
AVERAGE4
CYSTECTOMY5
653
Major Bladder Procedures W MCC
6.0456
11.9
Yes
$35,706
654
Major Bladder Procedures W CC
3.0267
7.2
Yes
$17,876
655
Major Bladder Procedures W/O CC/MCC
2.2796
4.8
Yes
$13,464
707
Major Male Pelvic Procedures W CC/MCC
1.7753
2.8
No
$10,485
708
Major Male Pelvic Procedures W/O CC/MCC
1.3146
1.4
No
$7,764
749
Other Female Reproductive System O.R. Procedures W CC/
MCC
2.6452
6.1
No
$15,623
750
Other Female Reproductive System O.R. Procedures W/O
CC/MCC
1.3346
2.4
No
$7,882
NEPHRECTOMY
656
Kidney and Ureter Procedures for Neoplasm W MCC
3.4617
6.8
No
$20,455
657
Kidney and Ureter Procedures for Neoplasm W CC
2.0091
4.2
No
$11,866
658
Kidney and Ureter Procedures for Neoplasm W/O CC/MCC
1.5337
2.6
No
$9,058
659
Kidney and Ureter Procedures for Non-Neoplasm W MCC
3.4848
7.5
Yes
$20,582
660
Kidney and Ureter Procedures for Non-Neoplasm W CC
1.9030
4.1
Yes
$11,239
661
Kidney and Ureter Procedures for Non-Neoplasm W/O CC/
MCC
1.3981
2.3
Yes
$8,257
PROSTATECTOMY6
665
Prostatectomy W MCC
3.1132
8.9
No
$18,387
666
Prostatectomy W CC
1.7878
4.6
No
$10,559
667
Prostatectomy W/O CC/MCC
0.9964
2.3
No
$5,885
707
Major Male Pelvic Procedures W CC/MCC
1.7753
2.8
No
$10,485
708
Major Male Pelvic Procedures W/O CC/MCC
1.3146
1.4
No
$7,764
Notes:
1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term
Care Hospital Prospective Payment System Changes and FY2016 Rates Final Rule, 80 Fed. Reg. 49325-49843. http://www.gpo.gov/fdsys/pkg/FR-2015-0817/pdf/2015-19049.pdf. Published August 17, 2015.
2. W MCC in MS-DRG titles refers to secondary diagnosis codes that are designated as major complications or comorbidities. MS-DRGs W MCC have at least
one major secondary complication or comorbidity. Similarly, W CC in MS-DRG titles refers to secondary diagnosis codes designated as other (non-major)
complications or comorbidities, and MS-DRGs W CC have at least one other (non-major) secondary complication or comorbidity. MS-DRGs W/O CC/
MCCs have no secondary diagnoses that are designated as complications or comorbidities, major or otherwise. Note that some secondary diagnoses are
only designated as CCs or MCCs when the conditions were present on admission, and do not count as CCs or MCCs when the conditions are acquired in the
hospital during the stay.
3. Post-Acute Care Transfer (PACT) status refers to selected DRGs in which payment to the hospital may be reduced when the patient is discharged by being
transferred out. The DRGs impacted are those marked “Yes” and the patient must be transferred out before the geometric mean length of stay to certain
post-acute care providers, including rehabilitation hospitals, long term care hospitals, skilled nursing facilities, or to home under the care of a home health
agency. When these conditions are met, the DRG payment is converted to a per diem and payment is made as double the per diem rate for the first day plus
the per diem rate for each remaining day up to the full DRG payment.
4. Payment is based on the average standardized operating amount ($5,467.39) plus the capital standard amount ($438.75). Centers for Medicare & Medicaid
Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective
Payment System Changes and FY2016 Rates; Correction, 80 Fed. Reg. 60055-60069. Tables 1A-1E. http://www.gpo.gov/fdsys/pkg/FR-2015-10-05/
pdf/2015-25269.pdf. Published October 5, 2015. The payment rate shown is the standardized amounts for facilities with a wage index greater than one.
The average standard amounts shown also assume facilities receive the full quality update. The payment will also be adjusted by the Wage Index for specific
geographic locality. Therefore, payment for a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any
applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.
5. The DRG clusters vary depending on whether the principal diagnosis is related to the urinary tract (DRGs 653-655, 665-667), the male reproductive system
(DRGs 707-708), or the female reproductive system (DRGs 749-750).
6. Codes 0VB00ZZ, 0VB4ZZ for excision of prostate lesion or subtotal prostatectomy group to DRGs 715-718 when they are the only procedure performed.
This information is taken from the materials published by the Centers for Medicare and Medicaid Services and the American Medical Association and may be helpful to
providers in staying up to date on coding and billing of services. This information cannot guarantee coverage or reimbursement, and Medtronic makes no other representations
as to selecting codes for procedures or compliance with any other billing protocols or prerequisites. As with all claims, providers are responsible for exercising their independent
clinical judgment in selecting the codes that most accurately reflect the patient’s condition and procedures performed for a patient. Providers should refer to current, complete,
and authoritative publications such as AMA HCPCS Level II, CPT publications or insurer policies for selecting codes based on the care rendered to an individual patient, and may
wish to contact individual carriers, fiscal intermediaries, or other third-party payers as needed.
CPT® is a registered trademark of the American Medical Association. This information is for educational purposes only and is not intended to serve as reimbursement advice. It
is the responsibility of the provider to select the codes that most accurately reflect the patient’s condition and procedures performed, and to consult with each patient’s health
plan for appropriate reporting of each procedure. In all cases, services must be medically necessary, actually performed and appropriately documented.
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