Urology Coding Alert

Stop reporting separate imaging guidance next year.

If your urologist uses percutaneous nephrostolithotomy (PCNL) when treating kidney or ureteral stones with extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy won’t work, you won’t want to miss important updates coming in CPT^® 2023.

Here’s what you need to know about these code changes, along with potential payment changes for these codes announced in the 2023 Medicare Physician Fee Schedule (MPFS) proposed rule.

Alter Your 50080/50081 Thinking

While you will still choose from the same two PCNL procedure codes in 2023, you’ll need to pay attention to the revisions to these codes. CPT^® 2023 will update the descriptors of both as follows (emphasis added):

• 50080 (Percutaneous nephrolithotomynephrostolithotomy or pyelolithotomy pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or stone basket 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))
• 50081 (… complex (eg, stone[s] > 2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy) over 2 cm)

According to urology coding experts, these changes will bring more clarity to your coding of PCNL procedures and the other procedures urologists commonly report with them, such as stent or nephrostomy tube placement.

“PCNL coding has been causing confusion for some time,” says Melanie Scott, CPC, CRHC, CPPM, CMPE, director of operations at Five Valleys Urology in Missoula, Montana. “I think the change and update in wording will help and better describes what is part and parcel of a percutaneous nephrolithotomy and will therefore help coders with choosing the correct codes.”

For example, placement of a nephrostomy tube at the conclusion of the procedure is common in PCNL surgeries. Coding experts have long cautioned that this procedure is included in 50080 and 50081; however, the code descriptors now make this clear.

Important: Note that the differentiation between 50080 and 50081 is no longer simply whether the largest stone is over or under 2 cm. The updated code descriptors will allow you to differentiate between simple and complex procedures based on stone size and other details in the urologist’s documentation, such as multiple locations (including ureteral, and not just kidney, stones), and code accordingly.

“We will be able to use 50081 in a lot more cases (of course with good documentation from the surgeon) and it will remove the modifier 22 [Increased procedural services] use on CPT^® code 50080,” Scott adds.

Skip the Imaging Guidance Code

As noted above, CPT^® 2023 will add “including imaging guidance, when performed” to the descriptors for 50080 and 50081. That means you will no longer separately report imaging guidance when your provider uses that guidance to perform PCNL procedures, warns Stephanie N. Storck, CPC, CCS-P, a urology coding consultant in Glen Burnie, Maryland.

The examples below help demonstrate how these descriptor revisions will affect your coding.

Old way: Suppose your urologist uses fluoroscopic guidance to perform a PCNL procedure to remove a 1.4 cm kidney stone. For a 2022 date of service (DOS), you report the procedure using these codes:

• PCNL: Report 50080 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm).
• Guidance: Report 76000 (Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time) with modifier 26 (Professional component).

New way: Considering the same example with a 2023 DOS, you will report only one procedure code:

• PCNL and guidance: Report 50080 alone since the PCNL procedure was simple and imaging guidance in now included in the code.

“I think that bundling imaging into a CPT^® code for a procedure will be more common as we already can see in a lot of other CPT^® codes,” Scott says.

Look Ahead to Payment Changes

Because the PCNL codes will include imaging guidance time and services, the 2023 proposed MPFS includes potential updates to the work relative value units (RVUs) for these codes. Plus, the Centers for Medicare & Medicaid Services (CMS) RVS Update Committee (RUC) found in review of claims data that PCNL procedures are performed less than 50 percent of the time in inpatient places of service (POS), even though the relative value units (RVUs) for 50080 and 50081 result in reimbursement related to 90-day global periods.

“The work RVUs are going down after the last CPT^® and RUC review,” Storck says. “You would think they would go up,” because of imaging guidance being part of the code now, but that is not the case.

“In September 2021, the CPT Editorial Panel revised the descriptors to CPT codes 50080 … and 50081 …, that in recent claims data were identified via the site of service anomaly screen, to be performed less than 50 percent of the time in the inpatient setting, but both codes have 090 day global periods, which include post-op inpatient hospital E/M services as a component of their value, typical of major surgery codes. The revised code descriptors also include image guidance and nephrostomy tube placement, which were not present in the old descriptors, and were reported as procedures that were separate from CPT codes 50081 and 50082. These codes have not been reviewed for nearly 30 years,” the 2023 MPFS proposed rule states (www.federalregister.gov/d/2022-14562/p-479).

What’s changing: As a result of the code descriptor changes and the POS findings, the MPFS proposed rule recommends work RVUs of 12.11 for 50080 and 20.61 for 50081. Currently, 50080 has 15.74 work RVUs and 50081 has 23.50, Storck says. The table below shows the proposed reductions.

AUA stance: The American Urological Association (AUA) has stated in a policy and advocacy brief on its website (https:// community.auanet.org/blogs/policy-brief/2022/08/30/aua-meets-with-cms-on-proposed-medicare-physician) that it has “… urged CMS to finalize percutaneous nephrolithotomy (PCNL) CPT^® codes (50080 and 50081) as proposed by RUC, instead of the CMS-suggested crosswalk with CPT^® codes 36830 and 36818. The AUA believes CMS’ approach does not maintain the relativity of procedures, nor does it account for the time, mental effort or skill associated with CPT codes 50080 and 50081.”

Learn more: See the article “Brace for Reimbursement Changes Next Year, Thanks to CF Reduction” below for more information about the proposed conversion factor reduction that will also affect your reimbursement for not just PCNL procedures, but all services your urologist performs.

Stay tuned: To prepare for 2023, you’ll need to look beyond these PCNL changes. Watch for an article in the next issue of Urology Coding Alert for news about code changes related to mesh implantation, laparoscopic prostatectomy, transperineal laser ablation, and suture removal.