Reporting Adrenalectomy – An Overview of the Procedure and CPT Codes

Reporting Adrenalectomy – An Overview of the Procedure and CPT Codes Adrenalectomy is the surgical removal of one or both adrenal glands. This article explains in detail the procedure along with its CPT codes.

Outsource Strategies International 8596 E. 101st Street, Suite H Tulsa, OK 74133

An adrenalectomy is the surgical removal of one or both of your adrenal glands. Adrenal glands are two endocrine glands – one located above each kidney - that secrete hormones such as epinephrine, norepinephrine, androgens, estrogens, aldosterone and cortisol that help regulate many bodily functions related to your immune system, metabolism, blood sugar levels and blood pressure levels. One of the most common reasons for this surgical procedure is benign or cancerous tumors on your adrenal glands. The procedure to remove an adrenal gland is performed if the tumor is producing excess hormones or is large in size (more than 2 inches or 4 to 5 centimeters). Moreover, an adrenalectomy is also performed to remove cancer that has spread (metastasized) from another location, such as the kidney or lung. In most cases, surgeons may remove one or both of your adrenal glands if they contain a tumor. However, if only one adrenal gland is removed, the remaining adrenal gland will take over and provide full functioning without the need for ongoing medications. Accurate reporting of general surgery medical billing and coding has become difficult with the increasing body of regulations related to coding and code choices. Medical coding outsourcing helps providers ensure correct reporting of services rendered for appropriate reimbursement.

Types of Adrenalectomy Performing an adrenalectomy involves three main approaches  Minimally invasive (laparoscopic) – As part of this procedure, the surgeon makes small incisions in the abdomen and near belly button and inserts a tiny camera into one of the incisions to access the adrenal glands. Using instruments inserted into the incisions, the surgeon will disconnect the adrenal glands and cauterize the blood vessels. Regarded as a common procedure, this laparoscopic method involves faster recovery time.  Open adrenalectomy – The open procedure is usually performed for large or cancerous (malignant) tumors on the adrenal glands. In this procedure, the surgeon will make large incisions under the ribcage or on the sides of the body. These incisions provide access to the glands and the blood vessels attached to them.

The type of adrenalectomy to be performed will depend on a wide range of factors such as – the size of the tumor, type of tumor, relationship of tumor to surrounding organs, the specific condition affecting your adrenal gland and history of prior abdominal surgery.

There are several risk factors associated with adrenal gland injury, the major ones include – hormone imbalances – caused by the underlying disease, the surgery, or both. Other potential risk factors include – bleeding, pain, loss of bowel function, blood clots in the lungs, infections and damage to adjacent organs (spleen, pancreas). www.outsourcestrategies.com

918-221-7769

How are Patients prepared for an Adrenalectomy?

Before conducting an adrenalectomy, your physician will conduct a detailed physical examination in order to check other medical problems like blood pressure, blood sugar and heart or lung problems that the patient suffers from and confirm whether these problems are under control. Patients will be given details on the following aspects –  Potential risks of surgery and what to expect before, during and after the surgery  Type of anesthesia administered (in this case a general anesthesia will be given to patients)  Type of procedure to be performed (whether it’s a laparoscopic or an open adrenalectomy)  Detailed instructions on when to stop eating or drinking the night before the surgery or on the day of the surgery  Advice on whether to consume or stop normal medications before the surgery  Risks of infections  Recovery time Urologists or general surgeons performing adrenal gland surgery must use the relevant diagnosis and procedure codes to bill the procedure. The CPT codes for adrenalectomy include –  60540 - Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, trans-abdominal, lumbar or dorsal (separate procedure)  60545 - Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor  60650 - Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal Recovery after the Procedure Soon after completion of the adrenalectomy procedure, patients will be closely monitored and their blood pressure, heart rate and level of pain will be evaluated as they recover from the anesthesia. Typically, patients will feel tired or sleepy for an hour or so after the surgery. They may also have a sore throat (which is the result of placement of anesthesia tubes during surgery). The speed and level of recovery will mainly depend on the specific type of procedure administered.

www.outsourcestrategies.com

918-221-7769

One of the main concerns after conducting an adrenalectomy is related to checking the patient’s hormone balance. Several sets of lab tests will be done to define hormone imbalances/problems (if any). If the adrenalectomy removed both the adrenal glands, patients will receive supplemental drug therapy to replace the hormones that the adrenal glands normally produce.

In most cases, patients who have undergone a laparoscopic surgery may normally experience some amount of pain and discomfort at the incision sites, but much less than those patients who have had open surgery. In addition, patients may also feel some cramping or bloating caused by gas in the abdomen. The time of recovery after the surgery will differ from one individual to another and may depend on the type of procedure performed. For laparoscopic adrenalectomy, patients will have to stay in the hospital for at least 2-3 days and this number is expected to rise to 4-5 days in case of open adrenalectomy.

Patients are generally advised to avoid heavy lifting and vigorous activity for at least one month after surgery to avoid hernia formation at the incision. In addition, patients can take a shower after 2 days of surgery, but should avoid bathing (submerging the incisions in water) and swimming for 1 week.

Urologists or general surgeons performing adrenal gland surgery need to ensure coding accuracy to receive optimal reimbursement for their services. Partnering with a reliable and experienced medical billing and coding company can help providers ensure accurate reporting of adrenalectomy procedures for correct and on-time reimbursement.

www.outsourcestrategies.com

918-221-7769