Urology Coding Alert

Question: The surgeon did a first stage PCNL greater than 2cm. The patient returned a week later for the second stage PCNL, also greater than 2cm. Is it correct to report 50081 for both procedures?

Virginia Subscriber

Answer: Yes, 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm) is the correct procedure code for both encounters. On the claim for the second visit, append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to indicate you’re reporting the second stage of a procedure.

According to coding guidelines, modifier 58 applies when “the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure [staged]; b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure.”

Also note: A patient might sometimes have a large enough stone that the physician is unable to remove everything during a single encounter. In that situation the urologist will schedule a repeat procedure during the global period to complete the removal.