# PCNL thru existing tract?



## Jessim929 (May 6, 2019)

Hi all... I'm thinking I have two pieces of a three piece puzzle in this case and could REALLY use another opinion (or two)

Patient had a PCNL on 4/10/19. This is pertinent.

On 5/3, a right antegrade ureteroscopy with holmium laser lithotripsy and right ureteral stent exchange was performed. A double-lumen catheter was placed by IR directly prior to surgery. Patient was prepped and draped over the right nephrostomy tube. Two Amplatz wires were then placed under fluorscopy down to the bladder. The double-lumen catheter was removed and the UroMax dilating balloon was placed. A tract from the skin to the renal pelvis was dilated and over the balloon the working sheath was placed, then the balloon was deflated. It was removed going in with a flexible cystoscope. There were no stone fragments in the kidney, but the proximal ureter stent was encumbered with stones. Stones fractured with a 300 micron holmium laser and then basketed to remove. A stent was replaced. No nephrostomy tube replaced. 

My colleague seems to think a 50081 is appropriate here, but isn't that for the first access? That's why I'm leaning more towards the 50691 for the stone removal and 50694 for the stent placement. I'm just at a loss for the laser work... OH! And I should note that a 52353 and 52332 was authorized. 

Anyone have any insight here? 

Thanks!!!


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## drewvinson23 (May 10, 2019)

Your coworker is correct, this would be captured by 50081.

CPT 50081 does not make a distinction if it is a new or existing access.  This code includes the dilation of the nephrostomy tract to allow instruments into the kidney to do the lithotripsy.  It also includes an antegrade stent placement.

You would code CPT 50432 if your urologist creates a new access to kidney to perform the PCNL procedure.  If the new access is created, but not nephrostomy tube is left at the end of the procedure, you would need to add a modifier 52.  Sometimes the urologist will create his own access.  Other times the nephrostomy tract will have already been created by an interventional radiologist, or created at an earlier date (in which case, code 50432 should not be billed). 

The code you have selected here, 50694, is "Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; new access, without separate nephrostomy catheter"
This would be used when your provider is percutaneously creating a new nephrostomy tract and placing a ureteral stent in antegrade fashion, and does not place a separate nephrostomy catheter at the end of the procedure.  CPT 50693 is is a similiar procedure, although is it for when their is already a pre-existing nephrostomy tract.

Here is a good article about PCNL coding:

https://community.auanet.org/blogs/...ow-to-use-the-new-percutaneous-dilation-codes

Hope this helps,

Drew Vinson
CPC
NW Urology


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## Jessim929 (May 13, 2019)

Thank you soooo much! I was seeing so much conflicting info, I was getting dizzy!


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