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Radiology Coding Alert

Interventional Procedure Report:

Pass the PCNL Coding Test

Published on Tue May 23, 2006

See if you'd capture all the payment your practice deserves

Coding interventional procedures may be less painful than kidney stones, but deciphering the report is no easy task. Try your skills at this real-life example, offered by Donna Gullikson, CPC, RCC, CIC, division director and coding supervisor for MCBS in Augusta, Ga. 

Report: Existing percutaneous nephroureteral stent is removed and a catheter is advanced into the right renal collecting system under fluoro. Contrast is injected and filmed over the kidneys, ureter and bladder. Antegrade pyelogram demonstrates occlusive stone burden involving the entire renal pelvis lower and mid calyceal systems of the right kidney. A catheter was successfully advanced into the ureter and subsequently into the urinary bladder. A guidewire was positioned for working sheath placement.
 
Following serial dilatation, a 30F working sheath was placed for PCNL. Following successful PCNL, the working sheath is removed and a 24F anteater nephroureteral stent was placed without difficulty. The ureteral stent component is positioned in the distal ureter, and the uretereal stent was positioned in the renal pelvis.

ANSWER: 

Did you conquer the coding challenge? Read on to find out.

You should report at least four separate aspects of the procedure, depending on which services your physician provides:

1. Creating the PCNL (percutaneous nephrostolithotomy) tract for the lithotripsy applicator introduction: 50395 (Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous) and 74485 (Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation), says Kim French, CIC, director of interventional coding and reimbursement at Crouse Radiology Associates in Syracuse, N.Y., citing the advice of the Society of Interventional Radiology.

2. Exchanging the stent: 50387 (Removal and replacement of externally accessible transnephric ureteral stent [e.g., external/internal stent] requiring fluoroscopic guidance, including radiological supervision and interpretation).

3. Performing the antegrade pyelogram: 50394 (Injection procedure for pyelography [as nephrostogram, pyelostogram, antegrade pyeloureterograms] through nephrostomy or pyelostomy tube, or indwelling ureteral catheter) and CPT 74425 (Urography, antegrade [pyelostogram, nephrostogram, loopogram], radiological supervision and interpretation), French says, again citing SIR.

4. Performing the lithotripsy: Use either 50080 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm) or 50081 (... over 2 cm). Ensure the physician documents the stone's size.  

Note: If a physician team performs this portion of the service (such as an interventionalist and a urologist), determine in advance how to file the claim (whether you're coding for co-surgeons, surgical assistant, etc.).

Sum Up This PCNL Article

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Procedure: The physician creates the PCNL tract to introduce the lithotripsy applicator, exchanges the stent, performs the antegrade pyelogram, and performs the lithotripsy for a stone burden of the lower renal pelvis and right kidney mid calyceal systems.

CPT codes: 50395, 74485, 50387, 50394, 74425, and either 50080 for a stone up to 2 cm or 50081 for a stone over 2 cm.
 
ICD-9 code: 592.0 (Calculus of kidney).

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