Percutaneous Urologic Interventions
An Inside Look at G-U Coding
By David Zielske, MD, CPC-H, CCS, RCC
Percutaneous urologic interventions permit the urologist to access the urologic system via needle puncture, rather than accessing the organ directly. Perhaps the most common reason to perform percutaneous urologic intervention is the inability of the urologist to perform a similar procedure cystoscopically (examining the bladder with a scope). Pathologic conditions that can affect the urologic system and may require medical intervention include cysts, tumors, calculi, radiation fibrosis, retroperitoneal fibrosis, infection, renal failure, and iatrogenic injuries.
Case In Point
Kidney stones, for example, are a common condition that many of us have experienced in the past (or, unfortunately, may in the future!). Kidney stones by themselves do not cause a problem until they either become very large and infected or until they try to pass from the kidney down the ureter into the bladder. Occasionally, during a stone passage, the stone can become stuck in the ureter, resulting in inflammation and scar tissue at the site of impaction with possibly even obstruction of the renal collecting system. If left untreated, this may result in pain, infection, and possible kidney failure on the involved side.
What’s a Radiologist To Do?
If the urologist is unable to remove the stone during an endourologic procedure, the radiologist may be asked to perform a percutaneous procedure to alleviate the obstruction. This may include performance of a diagnostic antegrade nephrostogram (by placement of a needle into a renal calyx, injecting contrast, and obtaining images). Submit CPT® codes 50390 Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous and 74425 Urography, antegrade (pyelostogram, nephrostogram, loopogram),radiological supervision and interpretation for this.
If a blockage is identified and it is deemed necessary to place an externally accessible drainage tube, this tube is placed percutaneously through the patient’s flank into the pelvicalyceal system of the kidney. This is called a nephrostomy tube placement. Quite often a separate approach through a posterior calyx is utilized to obtain this access (as to avoid the major blood supply within the kidney) and an 8 French externally draining nephrostomy tube is sutured to the skin. Describe placement of a nephrostomy tube with CPT® codes 50392 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous and 74475 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation.
After any risk of infection has passed or if the original obstruction is “sterile,” the interventional radiologist may then pass a guide wire, sheath, and stent across the blockage. This may occur at the uretero-pelvic junction (UPJ) within the ureter, or at the uretero-vesicle junction (UVJ). The placement of a single catheter, which extends from the outside of the body, into the renal collecting system, coiling within the renal pelvis, and then continuing as a single long tube down into the bladder is called the placement of a nephroureteral stent. If performed as the initial procedure, report codes 50393 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous and 74480 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation to describe the complete procedure, and you should not bill a separate nephrostomy (50392, 74475). If the nephroureteral stent is placed at a later time, you should code the initial nephrostomy tube on the initial date of service, and submit codes 50393 and 74480 at the time of this subsequent procedure.
Occasionally, physicians will place completely separate nephrostomy tubes (coiled in the renal pelvis with a catheter extending to an outside drainage bag) and a completely separate double pigtail ureteral stent (usually measuring 22-26 cm in length, 6-8 French in size, and extending from the renal pelvis to the bladder; entirely internal in location). You should bill this completely separate nephrostomy and completely separate ureteral stent placement as two separate procedures due to the additional work involved using the combination of codes 50392, 74475, 50393, and 74480. It would be appropriate to add the 59 modifier to codes 50392 and 74475 due to CCI edits preventing this type of coding when a single continuous nephroureteral stent was placed.
If the patient returns to evaluate the tube function (e.g., leaking catheter), a catheter check of the tube may be performed by injecting contrast and obtaining images. Code this with 50394 Injection procedure for pyelography (as nephrostogram, pyelostogram, antegrade pyeloureterograms) through nephrostomy or pyelostomy tube, or indwelling ureteral catheter and 74425. If it is deemed necessary to change the tube, and contrast and fluoroscopic guidance is documented, add codes 50398 Change of nephrostomy or pyelostomy tube and 75984 Change of percutaneous tube or drainage catheter contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation If these procedures are performed via an ileal conduit, use codes 50684 Injection procedure for ureterography or ureteropyelography through ureterostomy or indwelling ureteral catheter and 74425 or 50688 Change of ureterostomy tube or externally accessible ureteral stent via ilealconduit and 75984 Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation for tube check or tube change, respectively.
All Inclusive Codes
Four codes developed in 2006 for interventional nephrology are considered all-inclusive codes. CPT® code 50387 Removal and replacement of externally accessible transnephric ureteral stent (eg, external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation was developed to describe the exchange of a nephroureteral stent. Code 50387 includes contrast injection and imaging, wire placement via the catheter into the bladder, complete removal of the existing nephroureteral catheter, placement of a completely new nephroureteral stent, and any fluoroscopy and additional imaging performed.
Reporting Removal and Replacement
Sometimes the nephroureteral or nephrostomy tube needs to be removed at the end of treatment. Due to complexities with removal of these tubes, code 50389 Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent) was created to allow reimbursement for these procedures. Note, however, that code 50389 requires documentation for the use of fluoroscopic guidance.
When an underlying stenosis or complete obstruction is identified that requires balloon dilation of the ureter, you should submit unlisted code 53899. Separately add established imaging code 74485 for balloon dilation of the ureter. You can also use codes 50395 Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous and 74485 when the endourologic surgeon requests assistance in dilating a tract between the skin and the kidney to allow placement of surgical devices for stone destruction and removal. This includes dilation of a tract either with very large dilators or use of a balloon measuring 7-8 mm in size to dilate the tract. Note, however, that 50395 is restricted for use when dilation is performed between the skin and the kidney-do not use it for dilation of the uretero-pelvic junction, ureter, or uretero-vesicle junction.
Nephrostomy tubes may be left in the patient for extended periods of time. When performing a tube replacement, use codes 50398 and 75984 to specify the removal and replacement of an externally draining nephrostomy tube (if contrast use is documented) via the same access.
Once the ureteral stent is in place, it may ultimately be removed cystoscopically. If it turns out that the ureteral stent has become calcified and breaks or tumor growth prevents the urologist from removing the stent via cystoscopy, the interventional radiologist may be asked to obtain a new percutaneous access for extraction of the ureteral stent. Complete procedure code 50382 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation describes needle access followed by placement of a sheath into the kidney, utilizing a loop snare into the ureter to retrieve all fragments of the ureteral stent, placement of a new ureteral stent with or without leaving an externally draining nephrostomy tube, and all associated imaging. Although there are multiple components to this procedure, code 50382 includes all aspects of it.
Similarly, if the urologist requests removal of the ureteral stent, but no replacement, 50384 Removal (via snare/capture of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation is appropriate. This procedure also includes percutaneous access, any associated imaging, and removal of the ureteral stent, with or without placement of an externally draining nephrostomy tube. With code 50384, a new ureteral stent is not placed. If ureteroplasty is performed during either of these procedures, codes 53899 and 74485 are separately and additionally reimbursable.
In 2008, two additional all-inclusive codes were developed for interventional procedures performed without the use of a cystoscope but through a trans-urethral approach. Code 50385 describes the removal and replacement of a double pigtail ureteral stent with a snare or similar device while code 50386 describes the removal only of a ureteral stent by this method. These codes include all imaging and guidance. Cystoscopic stent removal codes already exist.
Renal Cyst Imaging, Drainages, and Ablations
If there is an adjacent abscess or urinoma in the perinephric or retroperitoneal space, drainage of that fluid collection may also be separately reimbursable using codes 50021 Drainage of perirenal or renal abscess; percutaneous or 50961 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus with associated radiological imaging guidance code 75989.
Renal cyst imaging, drainages, and ablations are also performed by interventional radiologists. Codes 50390 and 74470 describe needle placement into a renal cyst with injection of contrast and interpretation of images. If a cyst ablation is medically necessary, the placement of a larger catheter and infusion of a sclerosing agent such as alcohol may be performed. This type of ablation is coded with unlisted urologic procedure code 53899. The alcohol is usually removed from the renal cyst within one hour or less.
A Whitaker test is a procedure that evaluates an abnormally dilated renal collecting system usually in younger patients. If the dilation is due to obstruction, eventual kidney death would occur if there is no intervention. Certain syndromes, including prune-belly syndrome, have a diffuse tissue weakness of urologic structures, resulting in physiologic dilation of the renal collecting system and ureters. Physiologic dilation requires no subsequent intervention. One of the methods to determine whether the dilation is physiologic or pathologic is the Whitaker test.
A nephrostomy tube or needle is placed into the renal collecting system (separately billable if documented) and a separate Foley catheter is placed into the bladder. Pressures are obtained in both locations, followed by fluid infusion through the nephrostomy tube. If a pressure gradient is present (due to a form of obstruction distally), a drainage tube is left in place until a separate intervention is performed to relieve the blockage.
Procedure codes for cystostomy (bladder drainage) include new CPT® 2008 codes 51000 Aspiration of bladder; by needle, 51005 Aspiration of bladder;by trocar or intracatheter, and 51010 Aspiration of bladder; with insertion of suprapubic catheter. These may be performed under ultrasound or CT guidance. Cystostomy tubes may also be exchanged. Use codes 51705 Change of cystostomy tube, simple and 51710 Change of cystostomy tube; complicated to describe simple and complex exchanges, respectively. Code 75984 may also be submitted if an exchange was performed utilizing contrast and fluoroscopic guidance. A simple exchange represents tube removal over a guide wire with placement of a new one over the same guide wire while a complex exchange may require a sinogram or re-dilation of the tract for successful exchange.
An unusual procedure is a complex removal of a Foley catheter. If the balloon of a Foley catheter does not deflate properly, the physician may need to percutaneously place a needle through the bladder into the balloon to rupture the balloon and allow the removal of the Foley catheter through the urethra. Submit code 51703 Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon) to describe this. You can additionally code any imaging guidance utilized.
Other renal procedures include biopsy of a mass, RF or cryoablation of a tumor, embolization of a tumor or varicocele, angioplasty, or stent placement in a renal arterial stenosis, and renal venous sampling for renin determination. CPT® codes describing all of these procedures are available, but are beyond the scope of this urologic discussion.