Urology Coding Alert

Be careful when other services are included in the procedure time.

When kidney or ureteral stones need treatment to resolve, they often can be dealt with by extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy. When the stones are too large (usually larger than 2 cm), too numerous, or too dense for those treatments, the urologist might opt for percutaneous nephrostolithotomy (PCNL) as a minimally invasive way to remove the stones.

What happens: While the patient is under general anesthesia, the urologist passes a small endoscope through the patient’s side directly into the kidney. The stone is broken up and the fragments are removed.

Coding conundrum: Although the associated codes for PCNL are simple to understand, check for other related services before submitting the claim. Otherwise, you could be leaving money on the table that your surgeon deserves.

Help is here: Follow these five tips to find success with PCNL procedures — including tips on how to watch for other services that are commonly performed during the same session that might be separately reportable.

Tip 1: Understand the Code Details

The current CPT^® manual includes two codes for PCNL. They are:

• 50080 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm)
• 50081 (... over 2 cm).

These codes reflect the actual surgical procedure; choose the appropriate option based on the size of the largest stone the urologist treats — not the stone burden. Take note that the work associated with both codes includes nephrostomy tract dilation, internal lithotripsy, stenting, and basket extraction.

Other possibilities: When the urologist performs renal access, report CPT^® code 50432 (Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation). Add modifier 52 (Reduced services) to 50432 to indicate that in this scenario the code does not include placement of a nephrostomy tube at the conclusion of the procedure.

Remember: While you may have previously used 50395 (Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous) for renal access, this code has been deleted and you should no longer use it.

Placement of a nephrostomy tube is now included in 50080 or 50081 (see below). Additionally, if your urologist accesses more than one site, you might be able to report a second instance of 50432-52. If so, you will need to include documentation explaining the extra service and append  modifier 59 (Distinct procedural service) to the second 50432-52 or modifier 22 (Increased procedural service) to the initial CPT^® code 50432-52 alone to explain the additional reimbursement you’re requesting, advises Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook. 

“Do not bill this code if the renal access has been obtained for you by an interventional radiologist prior to your procedure,” Ferragamo warns. “The interventional radiologist will then most likely bill code 50432.”

Tip 2: Verify Any Associated Imaging

Performing a nephrostogram to help guide the PCNL procedure is not uncommon. If your urologist does so and did not perform or report renal access with 50432, which includes a nephrostogram, then report 50430 (Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; new access) or, more likely, 50431 (… existing access) for that procedure. 

Caveat: Verify that your urologist performed the nephrostogram before reporting 50430 or 50431. This may not be a procedure every urologist performs with every PCNL. 

Pointer: If your urologist interprets the radiological films, be aware that 50430, 50431, and 50432 all include radiological supervision and interpretation which you, therefore, cannot code separately.

Tip 3: Remember the Nephrostomy Tube Placement is Included

Another commonly performed procedure with a PCNL is placement of a nephrostomy tube at the conclusion of the procedure.

“Placing a nephrostomy tube at the end of the case is included in 50080 and 50081 so should not be reported separately,” says Jonathan Rubenstein, MD, of Chesapeake Urology. “We have recommended code 50432 for the placement of the access at the beginning of the case as that is not part of 50080/81. A 52 modifier may be used because of the overlap of services of 50080/81.”

Tip 4: Make a Final Check for Renal Endoscopies

Finally, you may find that your urologist also performed an incision of an infundibular stricture during the PCNL procedure. If documentation shows he did perform this additional work, add 50557 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy) to the claim. 

Tip 5: Pay Attention to Other Procedures

Note other procedures you may bill if your urologist performed them during a PCNL include: 

• 52005 (Cystourethroscopy, with ureteral catheter­ization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service)
• 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type))
• 74420 (Urography, retrograde, with or without KUB) with modifier 26 (Professional component) to represent the portion of the procedure your physician performed.