Radiology Coding Alert

Define details of each step in the urinary tract imaging and check if any services are bundled.

If your practice codes for interventional radiology, you clearly have a challenge of complex procedures. You need to hone your coding skills as interventional radiology procedures involve complicated technical processes. Key to coding is the details of the procedures. Your radiologist may either perform the intervention or provide radiological supervision and interpretation (S&I).

Follow these key three steps to ease the pain of interventional radiology coding. Examples of nephrostomy procedure codes will help you understand the approach.

Step 1. Define Access to Get to the Right Code

In procedures needing an intervention, make sure you define access before you proceed to selecting a code for the procedure. The access used in the intervention is a key step to coding for the procedure.

Example: You may read that your physician did a percutaneous nephrostomy and injected contrast to do an imaging of the urinary tract. You submit code 50432 (Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance [e.g., ultrasound and/or fluoroscopy] and all associated radiological supervision and interpretation) for this procedure.

However, if your physician performed the same procedure with an already existing nephrostomy, you would submit code 50431 (Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance [e.g., ultrasound and fluoroscopy] and all associated radiological supervision and interpretation; existing access).

Reminder: The code 50432 has been revised in 2017. The revision includes the elimination of moderate sedation, also called conscious sedation, from this procedure. Use of moderate (conscious) sedation is no longer considered an inherent part of this procedure and you can now report it separately.

• To report moderate (conscious) sedation when provided by the same physician or other qualified health care professional who performs the procedure, you submit CPT^® 2017 codes99151, 99152, or 99153.
• To report moderate (conscious) sedation services provided by a physician or other qualified health care professional other than the provider performing the procedure, you submit the new CPT^® 2017 codes 99155, 99156, or 99157.

Note: For more details of moderate (conscious) sedation, refer to ‘CPT^® 2017: Use Updates To Refine Angioplasty and Sedation Coding in 2017’ published in the Radiology Coding Alert Vol 18n12.

Step 2. Procedure Details are Key

For any intervention, it is important that you read the procedure note in detail and check the technique and processes. Make sure you know the key steps involved in the procedure.

Example: Your physician may place a percutaneous nephroureteral catheter and do a radiological assessment of the ureters. For this procedure, you submit code 50433 (Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance [e.g., ultrasound and/or fluoroscopy] and all associated radiological supervision and interpretation, new access). This code typically applies to new access created for the nephroureteral catheter and the imaging o the ureters.

However, if your physician converts an existing nephrostomy to a nephroureteral access and does the imaging, you will submit code 50434 (Convert nephrostomy catheter to nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance [e.g., ultrasound and/or fluoroscopy] and all associated radiological supervision and interpretation, via pre-existing nephrostomy tract).

If your physician changed the nephrostomy catheter, you submit code 50435 (Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance [e.g., ultrasound and/or fluoroscopy] and all associated radiological supervision and interpretation). On the other hand, if your physician removed the nephrostomy catheter, you submit code 50389 (Removal of nephrostomy tube, requiring fluoroscopic guidance [e.g., with concurrent indwelling ureteral stent]).

Step 3. Confirm the Services Provided

Your physician may not always perform the intervention. Instead, the services of your radiologist may only be limited to supervision and interpretation. To be able to earn for your physician’s services, make sure you know what exactly your physician did.

Example: You may read that your physician provided radiological supervision for an antegrade nephrostogram and interpreted the results of the images obtained. In this scenario, the most appropriate code is 74425 (Urography, antegrade [pyelostogram, nephrostogram, loopogram], radiological supervision and interpretation). You should not submit codes 50430 or 50431 for these services.

Watch the bundle: You do not submit code 74425 with codes 50432 and 50431 as the services are bundled. The codes 50432 and 50431 are inclusive of the nephrostogram and the radiological supervision and interpretation. Similarly, there is a bundle for 74425 and codes 50433, 50434, 50435.

For more details of percutaneous procedure coding, refer to update published in ‘Reviews in Urology’ (Rev Urol. 2016; 18(1): 38–43). You can access this on: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859928/.