Urology Coding Alert

Check out this scenario to stay in the game.

If you’re like most urology coders, some procedures give you trouble no matter how many times you see them. That’s why we’ve asked Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coding expert and consultant in Glen Burnie, Maryland, to help give you the answers you’re looking for.

In this first installment of a multipart series, she’ll be reviewing a percutaneous nephrolithotomy (PCNL) procedure and responding with her advice.

Review This Case for Accurate Application of 50081

Procedure notes: A patient had a PCNL with stent insertion on a 2.4 cm stone in the right kidney on 11/03/2023. On 12/01/2023, the patient was in severe pain and returned for a right antegrade ureteroscopy with holmium laser lithotripsy and right ureteral stent exchange. Prior to the surgery, the interventional radiologist reopened the previous nephrostomy site and placed a placed a double-lumen ureteral catheter into the kidney and collecting system. For the procedure, the urologist then placed two guidewires through the collecting system under fluoroscopic guidance down to the bladder and removed the double lumen catheter. The ureteral access sheath was introduced over the guidewires. The guidewires were exchanged with an extra stiff wire. Balloon dilation was then performed to enable the nephroscope to enter the collecting system. The sheath was removed with the deflated dilating balloon. The flexible ureteroscope was then utilized to identify the stone in the urinary tract. Fragmentation in the kidney was performed with laser fiber and remaining fragments were removed with stone basket was completed. Following complete stone removal, visual inspection of the tract was performed. No stone fragments were left in the kidney. The urologist noticed upon visualization that the proximal portion of the previously placed ureteral stent in the upper ureter was encrusted with stones. The urologist fractured the stones with a laser before basketing them for removal. The urologist replaced the stent, but the nephrostomy tube was not replaced at the end of the surgery.

Code the Initial PCNL

Storck’s advice: Capture the PCNL with 50081 (Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; complex (eg, stone[s] > 2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy). This code captures the appropriate size of the stone, as well as covering the fragmentation of several stones.

CPT^® codes 50080 (Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; simple (eg, stone[s] up to 2 cm in single location of kidney or renal pelvis, nonbranching stones)) and 50081 include antegrade stent placement, basket extraction and any other endoscopy performed. These codes do not make a distinction between whether an access is new or existing. The operative report would also have to include separate documentation if a nephrostogram or image guidance is performed. Pay close attention to the operative report.

CPT^® codes 50080 and 50081 do not include the dilation of the nephrostomy tract to allow larger urologic instruments into the kidney to perform the lithotripsy to fracture stones. For these procedures, report 50436 (Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (eg, ultrasound and/ or fluoroscopy) and all associated radiological supervision and interpretation, with postprocedure tube placement, when performed). If the urologist dilates a new access site (nephrostomy) into the kidneys to perform the PCNL procedure, use 50437 (… including new access into the renal collecting system). If the interventional radiologist created the initial access, the urologist should report 50436 for the dilation because there is already an existing opening.

Medicare does not always follow CPT^® guidelines. According to the Medicare National Correct Coding Initiative (NCCI), CPT^® codes 50436 and 50437 are considered bundled into code 50080 and 50081. Therefore, reporting either 50436 or 50437 in conjunction with either 50080 or 50081 will require appending modifier 59 (Distinct procedural service), XU (Unusual separate service), or XS (Separate organ or structure) to be accurately processed and paid by Medicare and most private payers.

If dilation is performed through either an existing or new access and a nephrostomy tube is not inserted at the end of the procedure, do not add modifier 52 (Reduced services).

The codes listed above include the tube placement only if performed.

Coding caution: Pay close attention to which provider created the initial access. The creation of the initial nephrostomy by the interventional radiologist is reported separately. However, CPT^® parenthetical notes prevent reporting of the initial access by the urologist performing the PCNL if performed on the same side. There is a Medicare NCCI edit with a modifier indicator of 1. If the urologist creates another access site on the contralateral side of the patient or on a different site, a modifier 59 with specific documentation can be reported separately with 50080 or 50081.

Why Don’t These Codes Apply?

Neither code 50561 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus) nor 50961 (Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus) would be the correct code for the procedure. CPT^® code 50561 would be used if a stone was removed, but would not be used if lithotripsy was performed, and 50961 is a retrograde (against the flow of urine) procedure performed through a ureterostomy (ureter exiting the skin).

Beware of Overbilling for Inclusive Procedures During PCNLs

If your urologist performs a PCNL, they may place a nephrostomy tube at the end of the procedure. Since placement is already included in codes 50080 and 50081, don’t report the nephrostomy tube separately.

Coding note: 50080 and 50081 may only be reported once per side. For bilateral procedures, report these codes with modifier 50 (Bilateral procedure).