Urology Coding Alert

Question:  A patient had a PCNL on 04/03/2019. On 05/03/2019 the patient returned for a right antegrade ureteroscopy with holmium laser lithotripsy and right ureteral stent exchange. The urologist placed a double-lumen catheter by IR directly prior to surgery. Two Amplatz wires were placed under fluoroscopy down to the bladder. The urologist removed the double-lumen catheter and placed the UroMax dilating balloon. He dilated a tract from the skin to the renal pelvis. The working sheath was placed over the balloon, then the balloon was deflated. It was removed going in with a flexible cystoscope. There were no stone fragments in the kidney, but the proximal portion of the ureteral stent in the upper ureter was encumbered with stones. The stones were fractured by laser and then basketed for removal. The urologist replaced a stent but not the nephrostomy tube.

My colleague thinks 50081 is appropriate here, but isn’t that for the first access? I’m leaning more toward 50961 for the ureteral stone removal and 50694 for the stent placement. What do you recommend?

Alabama Subscriber

Answer: Your coworker is correct for the initial PCNL (percutaneous nephrolithotomy), which would most likely be captured by 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm).

CPT^® code 50081 does not make a distinction between new or existing access. This code includes the dilation of the nephrostomy tract to allow instruments into the kidney to do the lithotripsy. It also includes an antegrade stent placement.

You would report 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) if your urologist creates a new access to kidney to perform the PCNL procedure. If the new access is created, but a nephrostomy tube is not left at the end of the procedure, add modifier 52 (Reduced services). Sometimes the urologist will create his own access. Other times the nephrostomy tract will have already been created by an interventional radiologist or created at an earlier date (in which case, you should not bill code 50432).

For the second procedure on 05/03/2019, report code 50961 (Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus) along with code 50694 (Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; new access, without separate nephrostomy catheter). Since these later procedures fall within the 90-day global associated with the initial PCNL, add modifier 79 (Unrelated procedure or service by the same physician…during the postoperative period) to both 50961 and 50694.