# antegrade pyelogram - Reason for Study



## Lynda Wetter (Feb 6, 2012)

Do i code the injection and the tube placement? 
50390 74425 & 50392 74475
or just...50392 74475


Reason for Study: HYDRONEPHROSIS  
Reason For Visit: ACUTE RENAL FAILURE HYPERKALEMIA   
Procedures: 1. Nonvascular ultrasound, limited.  
2. Ultrasound guided aspiration.  
3. Fluoroscopically guided drain placement.  
4. Antegrade nephrostogram.   
Complications: None.  
Medications: 1 mg Versed and 50 mcg fentanyl IV.   

Technique: After the risks, benefits and alternatives were explained to the patient and written, informed consent was obtained, the patient was placed prone on the fluoroscopic table. The left back and flank were prepped and draped in sterile fashion and 1% lidocaine was used for local anesthesia. With ultrasonographic control the posterior calyx of the left kidney was accessed with an 21-gauge needle and then an 018 inch wire was placed. The needle was exchanged for the Accustick system and contrast was instilled to*confirm position​*. Over the wire exchange was then made for 6 French fascial dilator and then an 8 French percutaneous nephrostomy tube. Final position was confirmed with spot fluoroscopy. Antegrade nephrostogram was performed. Catheter was secured to the skin at the exit site with 2-0 silk suture. There were no complications and the patient tolerated the procedure well.   
Findings: 1. Minimal-moderate hydronephrosis left kidney. A permanent image was obtained and stored.  
2. Ultrasound guided percutaneous access to left renal collecting system via a midpole calyx.  
3. Fluoroscopically guided 8 French percutaneous nephrostomy tube placement with pigtail in the renal pelvis. Permanent image stored in the digital picture archive.  
4. Antegrade nephrostogram demonstrates moderate hydronephrosis and   proximal hydroureter left kidney. 
  Impression: Successful left percutaneous nephrostomy tube placement with ultrasound and fluoroscopic guidance.


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## Rajebpt (Feb 6, 2012)

Hi,

First contrast injection is performed to confirm contrast injection and the second is performed after tube placement so I believe we can coded only tube placement.

50392
74475

Your thoughts!


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## Lynda Wetter (Feb 7, 2012)

Thats what i thought too!
But, what if the documentation was not so clear. What if it simply stated that the calyx was entered and contrast injected and the they place the tube. What if it doesnt say to confirm placement or medical necessity? Is the contrast injection still considered part of the tube placement??
Thanks!!


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## cblack712 (Feb 8, 2012)

Contrast injection is considered integral to the tube placement. With this report you would only code the 50392, 74475. The only time that the 50390/74425 can be coded is when the calyx is accessed and shows reason for the tube to be placed - ie after contrast injection into the renal calyx showed hydronephrosis the decision was made to place a nephrostomy tube. The injection must be diagnostic and since it isn't considered a separate service there is no need to state either medical necessity or confirmation. 50390/74425 is not frequently billed with 50392/74425. 
Also - this is a report where you can bill for conscious sedation (99144) if the physician dictates the amount of time used and that it was physician monitored - ect.....  


in the event that you do ever have to bill them together you will have to use a 59 modifier on 50390. 
Hope that helps. If you are new to IR coding I would suggest Dr. Z IR coding book - it is a great resource.


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## Lynda Wetter (Feb 10, 2012)

Thanks, thats what I thought, but there was a difference of opinion in the office. I read Dr.Z and his great examples in regards to this. I was certain what to do but it never hurts to see others opinions!!!    I'm deffinately still learning when it comes to IR!! And YES I agree Dr.Z is a great resource.
Thanks so much for the input!!


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