Urology Coding Alert

Question: I heard there are new guidelines this year for reporting percutaneous nephrolithotomy (PCNL) procedures. My urologist performed a PCNL, creating their own access and performing the dilation. Documentation states they placed a nephrostomy tube and removed a 1.8 cm stone. Can I report 50080 and 50436 or 50432?

New York Subscriber

Answer: Based on the information provided, you are correct that 50080 (Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone 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)) is the proper code for the PCNL procedure. However, you should not separately report 50436 (Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (eg, ultrasound and/ or fluoroscopy) and all associated radiological supervision and interpretation, with postprocedure tube placement, when performed) or 50437 (… including new access into the renal collecting system) for the dilation procedure.

The National Correct Coding Initiative (NCCI) edits bundle both 50436 and 50437 codes with 50080 and 50081. Unless your urologist performed the dilation in a distinctly separate way from the PCNL procedure, you should not unbundle the codes, even though the bundles carry a modifier indicator of “1.” If the urologist performed dilation on the contralateral side (separate location), you might be able to report the PCNL and dilation access codes separately using modifier 59 (Distinct procedural service) or modifier XU (Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service).

Additionally: You also should not separately 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).

Here’s why: Although NCCI does not bundle 50432 with 50436 or 50437, the CPT^® code descriptor makes it clear you should include the tube placement in the main procedure.

You are correct that there were changes starting January 1, 2023. CPT^® 2023 updated the descriptors of the codes 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)

As noted in the article “Prepare Now for PCNL Code, Pay Changes Coming Your Way in January” in Urology Coding Alert, Vol. 24, No. 10, 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). They also clarify that nephrostomy tube placement and imaging guidance are included.