CPT® 2016: Urinary Interventional Coding

CPT® 2016: Urinary Interventional Coding

Part 1: Understand what changes affect percutaneous urinary interventional coding.

For 2016, the biggest CPT® coding changes affecting interventional radiology occur within the subspecialties of urinary, biliary, and neurologic intervention. This month, let’s focus on percutaneous urinary interventional coding, and in upcoming articles we’ll cover biliary and neurologic intervention codes.

New Codes for 2016

There are 12 new urinary intervention codes for 2016. The new codes describe:

Diagnostic nephrostogram 

50430 Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; new access

50431       existing access

Percutaneous nephrostomy and nephroureteral catheters 

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

50433 Placement of nephroureteral catheter, 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

50434 Convert nephrostomy catheter to nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, via pre-existing nephrostomy tract

50435 Exchange 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

Ureteral stents 

50693 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; pre-existing nephrostomy tract

50694 new access, without separate nephrostomy catheter

50695 new access, with separate nephrostomy catheter

Three add-on procedures: biopsy,
embolization, and ureteroplasty 

+50606 Endoluminal biopsy of ureter and/or renal pelvis, non-endoscopic, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)

+50705 Ureteral embolization or occlusion, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)

+50706 Balloon dilation, ureteral stricture, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure)

The new codes were well thought out to cover the majority of performed urinary cases, and all include both the surgical and supervision and interpretation (S&I) components of the procedure. All procedures listed above also bundle the use of imaging guidance, including fluoroscopy, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI).

New CPT® guidelines instruct us to code separately for each treated renal collecting system. A renal collecting system consists of the renal calyces, renal pelvis, ureteropelvic junction, and the ureter all the way to the bladder. A duplicated collecting system is a normal variant that occurs in approximately 1 percent of the population. This may result in two procedures of the same type for a single kidney (each treated, duplicate system is coded separately).

Nephrostogram

Nephrostogram (50430 and 50431) is performed to evaluate the renal collecting system for patency, stones, strictures, malignancy, and leaks. These abnormalities can occur anywhere in the collecting system, but most often are between the ureteropelvic junction and the bladder. The nephrostogram may be performed via a new access (placing a needle or catheter through the back into the pelvocalyceal system) or a pre-existing catheter (usually an existing nephrostomy catheter). Contrast is injected and imaging is performed and interpreted. The procedure is reported with 50430 when performed via a new access, or with 50431 when performed via an existing access. Because imaging guidance is performed, be sure the ultrasound, CT, or MRI tech does not charge a guidance code when the access uses one of these imaging guidance modalities.

Nephrostogram is bundled with the new nephrostomy catheter, nephroureteral catheter, and ureteral stent placement codes. The nephrostogram codes may be used as a base code for codes +50606, +50705, and +50706, but only if a catheter is not placed, replaced, or converted.

Example: A patient has an existing nephrostomy catheter. Diagnostic nephrostogram is performed (50431), demonstrating a mid-ureteral stenosis. Ureteroplasty is performed (+50706). The nephrostomy tube is removed and not replaced at the end of the procedure (50389).

The following codes do not involve placement of a ureteral stent:

  • 50432 describes the initial placement of a percutaneous nephrostomy (PCN) catheter via a new access and includes 50430.
  • 50433 describes the initial placement of a percutaneous nephroureteral (PNU) catheter via a new access and includes 50430.
  • 50434 describes the conversion of an existing nephrostomy catheter to nephroureteral catheter (removal of the PCN catheter and placement of the PNU catheter over a wire) and includes 50431.
  • 50435 describes the exchange of a PCU catheter for a new nephrostomy catheter or the exchange of a nephroureteral catheter for a nephrostomy catheter and includes 50431.

Example: The patient recently underwent nephrostomy catheter placement for ureteral obstruction and infection. Now that the infection has subsided, a diagnostic nephrostogram (50431) is performed, showing mid-ureteral stenosis. The nephrostomy catheter is removed over a wire and a nephroureteral catheter is advanced with the tip in the bladder and secured in position (Add 50434 for the conversion of a nephrostomy to a nephroureteral catheter. Delete 50431 as bundled with this conversion.).

Initial Ureteral Stent Placements

There are three new codes for initial ureteral stent placements: one via an existing access and two from a new access:

  • 50693 describes the placement of a double pigtail ureteral stent via an existing access (prior nephrostomy catheter or nephroureteral catheter access) and includes placing an externally draining nephrostomy catheter (if done).
  • 50694 describes the placement of a double pigtail ureteral stent via a new access without leaving a nephrostomy catheter at the end of the procedure.
  • 50695 describes the placement of a double pigtail ureteral stent via a new access with separate placement of an externally draining nephrostomy catheter.

All three codes include an initial nephrostogram (50430, 50431) and all imaging guidance (fluoroscopy, ultrasound, CT, MRI) used during the procedure.

Example: A patient with an existing nephrostomy catheter presents for conversion to an internalized double pigtail ureteral stent (50693). At the end of the procedure, a new nephrostomy is placed over the guidewire due to excessive bleeding during the procedure (this is bundled with ureteral stent placement).

Deleted and Revised Urinary Codes

Also in this section of CPT®, six codes were deleted (50392, 50393, 50394, 50398, 74475, and 74480) and two were revised: 50390 Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous and 74425 Urography, antegrade (pyelostogram, nephrostogram, loopogram), radiological supervision and interpretation. Code 50390 is now used for placing a needle into a renal cyst to inject contrast or remove fluid. Code 74425 is still used to describe a nephrostogram, but only from a retrograde approach, as done via an ileal conduit, with injection code 50684 Injection procedure for ureterography or ureteropyelography through ureterostomy or indwelling ureteral catheter.

New Add-on Codes

Codes +50606, +50705, and +50706 require a base code, which can be any of the catheter placement, conversion, or exchange codes described above, as well as diagnostic nephrostogram codes 50430 and 50431.

+50606 describes an endoluminal biopsy (brush, needle, or alligator forceps) of the urinary collecting system (renal calyx, renal pelvis, or ureter). If a duplicated collecting system (e.g., bilateral ureters, duplicated ureters) is also biopsied, report +50606 a second time for the separate procedure.

+50705 describes ureteral embolization and is usually performed to treat a fistula or urinary leak due to an invasive malignancy. Once embolized, a permanent nephrostomy catheter will be necessary for urinary drainage. Ureteral embolization is coded once per ureter.

+50706 describes ureteroplasty (balloon dilation) of the ureteropelvic junction (UPJ) or the ureter for treatment of a stenosis or occlusion.

The three add-on procedure codes can be submitted once per day, per collecting system and can be performed via any percutaneous access (including a renal access, an ileal conduit, a cystostomy, a ureterostomy, and via a trans-urethral approach).

Example: The patient has a nephroureteral catheter in place via an ileal conduit. The patient has a known filling defect in the region of the UPJ, and is here for biopsy. The catheter is removed over a guidewire and a sheath is placed up to the abnormality. A brush biopsy is performed and sent for pathology (+50606). A new nephroureteral stent is placed over the wire via the ileal conduit (50688 Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit, 75984 Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation).

NOTE: This procedure is via an ileal conduit, not via the flank, which changes coding for urinary intervention.

What Stays the Same in 2016

Existing codes describe procedures:

  • Via an ileal conduit approach (e.g., catheter exchange codes 50688/75984 and nephrostogram codes 50684/74425);
  • Via a transurethral approach (e.g., transurethral ureteral stent exchange code 50385 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation and transurethral ureteral stent removal code 50386 Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation); and
  • Of non-externally accessible ureteral stents (e.g., percutaneous ureteral stent exchange code 50382 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation and percutaneous ureteral stent removal code 50384 Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation).

Other procedures with existing codes include nephroureteral catheter exchange (50387 Removal and replacement of externally accessible transnephric ureteral stent (eg, external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation), nephroureteral or nephrostomy catheter removal (50389 Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent)), and creation of an access site (50395 Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous) with dilation of a tract between the skin and kidney for stone extraction.

With the new codes added in 2016, a comprehensive set of urinary codes is now available to describe almost every procedure performed in the urinary system. The opportunity for coding specificity has never been better.


 

David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC, (Dr. Z) is the founder and CEO of ZHealth, LLC, and ZHealth Publishing, LLC. He practiced as an interventional radiologist for 15 years and has 16 years of experience as a coding reviewer and educator. Dr. Z is Board Certified in Radiology with the Certification of Added Qualification (CAQ) in Interventional Radiology (ABR) (1995, 2005). He was on the AAPC National Advisory Board from 2005-2009, and is a member of the Nashville, Tenn., local chapter.

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