Urology Coding Alert

Question: The surgeon excised a large renal cyst (16 cm) at the level of normal kidney parenchyma. She removed the entire cyst from the upper pole and dissected free and placed a large fat graft (from an omental flap) over the bed of the upper pole cavity to prevent regrowth of the cyst. She then removed a second, 4 cm cyst from the lateral mid-pole. How should I code this surgery?

Wyoming Subscriber

Answer: For the excision of kidney cysts via an open approach use CPT® code 50280 (Excision or unroofing of cyst(s) of kidney). This code includes removal of multiple cysts. You can also report add-on code +49905 (Omental flap, intra-abdominal (List separately in addition to code for primary procedure)) without a modifier.

Laparoscopic difference: If the surgeon had used a laparoscopic approach to remove the cysts, you would submit 50541 (Laparoscopy, surgical; ablation of renal cysts) instead of code 50280. For the laparoscopic placement of the omental graft into the cyst cavity, use add-on code +49326 (Laparoscopy, surgical; with omentopexy (omental tacking procedure) (List separately in addition to code for primary procedure)).