Urology Coding Alert

To report the procedure, O'Dell settled on these CPT codes:

CPT Code 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting or basket extraction; over 2 cm) for the nephrostolithotomy and stone removal (the percutaneous nephrostomy and ultrasonic lithotripsy). The code includes dilation, internal lithotripsy and basket removal, all of which the urologist performed in this case. Because the stone removed from the kidney was more than 2 cm, O'Dell says, she chose that code rather than  50080 (... up to 2 cm).

Code 50395-51 (Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous; multiple procedures) for the percutaneous access. Modifier -51indicates that 50081is the primary procedure. Most Medicare carriers will append modifier -51on codes listed after the first line, but some non-Medicare carriers may not.

However: Many coders are still hesitant to report the two together. Pamela Arthur, CPC, coordinator of the billing department for Associated Physicians of the Medical College of Ohio in Toledo, points to the March 2003 edition of Coding Tips for the Urologist's Office. There, the American Urological Association maintained that, NCCI edits notwithstanding, 50395 is included in 50081. This indicates that the percutaneous nephrostolithotomy includes the access and dilation.

The article "specifically states that 50080 and 50081 include the access and the dilation," Arthur says, "and 50395 is only to be used when establishing a nephrostomy tract, without the nephrostolithotomy." Arthur also points out that the code description for 50081 includes dilation and establishing the tract. It's still a gray area, she says.

Best bet: Contact your carrier and ask how to handle billing both 50081 and 50395.

Some of the confusion stems from the early history of PCNL procedures, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York.

"A radiologist usually obtained kidney access with a fluoroscope before the urologist performed the PCNL in the OR," he says. "The radiologist coded 50395 for his work, and the urologist coded 50080 or 50081 for the PCNL."

As fluoroscopic technology improved, urologists were able to gain their own renal access for PCNL in the OR. In 1996, the AUA successfully lobbied to unbundle 50395 and other access codes from 50080 and 50081.

Turn 50392/50395 Bundle to Your Advantage

The code for placement of a nephrostomy tube is 50392 (Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous). However, in July 2004, NCCI bundled 50392 into 50395, indicating that only one of these codes should be reported per PCNL.

Opportunity: This leaves you with another solution to the 50081/50395 conundrum. "If you feel strongly that the access is included in the 50081 CPT definition, and the urologist places a nephrostomy tube at the end of the procedure, code 50081 and 50392-51," Ferragamo says.

"The payment will be similar, as the relative value units [RVUs] for both 50395 and 50392 are 4.66." In 2005, the RVUs will rise to 5.10 for 50392 and 5.08 for 50395, Ferragamo says.

Was It Complicated?

Use code 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; complicated) for the removal of the bladder stone.

"Whenever the doctor puts in his note that he had difficulty or it took a while to grasp [the stone] and pull it out," O'Dell says, "that's when I judge that the procedure is complicated."

In this case, the operative note led O'Dell to choose 52315 rather than 52310 (... simple).

Watch Globals When Picking CPT Codes

The previous stone removal, 50081, has a global period of 90 days. In order to be able to report the new codes in the global period of the previous procedure, O'Dell appended modifier -78 (Return to the operating room for a related procedure during the postoperative period) to all three codes.

Coders often append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to "second-look" procedures, but you can only do that if the documentation for the original surgery shows that the urologist planned to perform the procedures later, says Nancy Moore, urology coder for the Oregon Clinic in Portland. Since there was no such documentation, O'Dell opted for -78.

Since 50081 carries the most RVUs (33.69 for a fully implemented facility, according to the Medicare Physician Fee Schedule Database), you should list that first on the claim form, Arthur says.

The code for fluoroscopy - 76000 (Fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) - is bundled into 50395 and 52315, so O'Dell could not report it separately, Arthur says.

Since all three procedures were necessary due to the bilateral staghorn calculi, link the CPT codes to ICD-9 code 592.0 (Calculus of kidney).