Insertion of Nephrostomy Tube and Stent

[jtuominen]

Wondering how other may tackle the coding of this report:


HISTORY: 53-year-old female with left hydronephrosis secondary to
metastatic endometrial cancer.

FINDINGS: The procedure and risks were explained to the patient and
her family in detail. Under sterile technique, an antegrade pyelogram
was performed with a 22-gauge needle. Posterior mid calyx was selected
and an 18-gauge needle was inserted into the dilated collecting
system. A JBI catheter and wire were directed down the left ureter and
a distal left ureterogram was performed demonstrating high-grade
obstruction at the left ureterovesical junction secondary to malignant
obstruction. The wire was then exchanged for a Glidewire and the
catheter was advanced over the wire into the bladder. The wire was
then exchanged for an Amplatz superstiff wire. The tract was dilated
to 10 French and 8 French 22 cm double J ureteral stent was placed.
Following stent placement 8 French nephrostomy tube was placed in the
left intrarenal collecting system and left external drainage. After
initial external drainage, the nephrostomy tube will be capped for a
trial of internal drainage and if tolerated the nephrostomy tube can
be removed.

Fluorotime 6.2 minutes.

Contrast: 20 mL Hexabrix.

Local anesthetic 10 mL 1% lidocaine.

Conscious sedation: 3.5 mg IV Versed, 175 mcg IV fentanyl.

Sedation time: 20 minutes.

The patient was monitored by radiology nursing staff under my
supervision and remained stable throughout the study.

IMPRESSION:
1. Moderate left hydronephrosis and hydroureter secondary to
high-grade obstruction at the level of the left ureterovesical
junction.
2. Successful left ureteral stent placement and left nephrostomy
placement.

[syb9161]

Nephrostomy tube/stent placment is coded as follows.

(CPT code 50393) Percutaneous drainage or stent placement

(CPT code 53899) for dilation of ureter

If monitored sedation was rendered you would code (CPT code 99144) this is not the case according to the documentation.

Radiology codes are as follows:

(CPT code 74480) for procedure 50393
(CPT code 74485) for procedure 53899

Hope this help....

Shirley, CPC

[jtuominen]

Thanks Shirley, the rad techs in my department want to bill this one as

50393
74425

50390
74480

50392
74475

I think this is wayyy overbilled. Do you or others agree?

[Jim Pawloski]

Originally Posted by jtuominen

Thanks Shirley, the rad techs in my department want to bill this one as

50393
74425

50390
74480

50392
74475

I think this is wayyy overbilled. Do you or others agree?

I do not think this is way overbilled, but this is how I would bill for this
1.) 50390/ 74425 Antegrade Pyelogram
2. 53899/74485 should be billed since the ureter was dilated with a balloon catheter. (Ureteral Dilation)
3. 50393/74480 Ureteral stent placement
4. 50392/74475 Nephrostomy - External drainage tube was placed for drainage.

[dpeoples]

Originally Posted by jtuominen

Thanks Shirley, the rad techs in my department want to bill this one as

50393
74425

50390
74480

50392
74475

I think this is wayyy overbilled. Do you or others agree?

I do not think it is way overbilled, however...

I would not code the diagnostic components (50390/74425) because per history, the diagnosis had already been determined (hydronephrosis) and these codes are considered components of the the other codes per CCI. If it is a true diagnostic procedure, then you will need to ad modifier 59.

You will probably need to add modifier 59 to 50392/74475 because they also bundle with 50393/74480 (per CCI).

HTH

[dpeoples]

Originally Posted by dpeoples

I do not think it is way overbilled, however...

I would not code the diagnostic components (50390/74425) because per history, the diagnosis had already been determined (hydronephrosis) and these codes are considered components of the the other codes per CCI. If it is a true diagnostic procedure, then you will need to ad modifier 59.

You will probably need to add modifier 59 to 50392/74475 because they also bundle with 50393/74480 (per CCI).

HTH

I forgot to mention the dilation. I would probably use 50395 Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous.

[jtuominen]

Thanks Danny, I guess I feel conflicted about billing the 50390 as well because the diagnosis for hydronephrosis is already established via CT Scan of the pelvis earlier in the day.

I guess I wondered about 50393 and 50392 because I felt uncertain about the doctor's language when he states the " nephrostomy tube was placed in the left intrarenal collecting system and left external drainage". Does this phrase intend to mean that the nephrostomy tube was placed within the renal pelvis? If so then I agree with determination to include coding 50392 and 50393.

We have been haggling over the true definition of 50395 for a while now, last time we talked about it, it was decided that is was to be used only to record over-dilation of a tract. But after you mentioned the above I found a CPT Assistant that stated to use it regardless of the size of the tract created, so Im going to give that one a go. Its CPT Assistant October 2005 pages 18-20. Thanks again Danny!