5 Tips Help You Grasp PCNL Procedure Coding
Missing separately reportable procedures will cost your practice.
Urology coders must know how to code many types of kidney procedures, including many stone removal surgeries. Extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy are common surgical options; however, sometimes the stones are too large or too dense, or there are too many stones for these procedures to be the effective treatment choice.
In those cases, the urologist might turn to percutaneous nephrostolithotomy (PCNL) as a minimally invasive way to remove the stones. By focusing on five tips, coders can hone their PCNL coding skills.
1. Understand the Procedure
The first step you should take when deciding how to report a procedure is understanding how the physician performs the surgery.
For PCNL, while the patient is under general anesthesia, the urologist inserts a small incision in the patient’s back directly over the affected kidney. The surgeon then inserts a nephrostomy tube via an endoscope, creating a tunnel directly into the kidney (or into the renal pelvis with pyelostolithotomy). The stone is then either removed or broken into fragments and the fragments are removed.
2. Differentiate 50080 and 50081
The CPT® code book includes two codes for PCNL. They are:
50080 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm
50081 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm
Choose the appropriate option based on the size of the largest stone the urologist treats — not the total stone burden. Based on the descriptors, both codes include the work associated with nephrostomy tract dilation, internal lithotripsy, stenting, and basket extraction.
These codes include the dilation of the nephrostomy tract to allow instruments into the kidney to do the lithotripsy.
3. Check for Renal Access
If the urologist creates new access to the kidney to perform the PCNL procedure, report CPT® code 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. If the urologist creates new access but does not leave a nephrostomy tube in place at the end of the PCNL procedure, add modifier 52 Reduced services to 50432 to indicate that this scenario does not represent the full descriptor of the code.
Sometimes the urologist will create an access. Other times the nephrostomy tract will have already been created by an interventional radiologist or created at an earlier date (in which case, you should not bill code 50432).
Remember: CPT® codes 50080 and 50081 do not make a distinction between new or existing access. You’ll still use those codes for the PCNL procedure but will add or leave off 50432 based on access type.
If the urologist places a nephrostomy tube at the end of the procedure, do not separately report it. Effective Jan. 1, 2019, introduction code 50395 was deleted and guide placement is now included in 50080 or 50081. While you can report 50432-52 to capture payment for the access procedure, you cannot capture reimbursement for the actual nephrostomy tube placement.
If, however, the urologist accesses more than one site, you may be able to report a second instance of 50432-52. If so, you will need to include documentation explaining the extra service and append modifier 59 Distinct procedural service to the second 50432-52. Some payers may prefer you add modifier 22 Increased procedural services to the initial CPT® code 50432-52 to explain the additional reimbursement you’re requesting. Check with your payer.
4. Capture Any Associated Imaging
The urologist may perform a nephrostogram for guidance during the PCNL procedure. If you report renal access with 50432, that includes a nephrostogram.
If the urologist does not perform the access, report 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 or, more likely, 50431 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; existing access for the nephrostogram.
If the urologist interprets the radiological films, be aware that 50430, 50431, and 50432 include radiological supervision and interpretation. Do not separately report radiological supervision and interpretation with these codes.
5. Watch for Renal Endoscopies
During a PCNL procedure, the surgeon may also perform an incision of an infundibular stricture. If documentation shows the urologist performed this additional work, report 50557 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy.
Other procedures the urologist may perform during a PCNL include:
52005 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service
52332 Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)
74420 Urography, retrograde, with or without KUB with modifier 26 Professional component attached
Test Your Skills
Now that you’ve read about how to report PCNL surgeries, try your hand at coding this sample case.
Scenario: The surgeon performs a left percutaneous nephrostolithotomy for a renal pelvic stone less than 2 cm in size, an antegrade left ureteral stent placement, and left nephrostomy tube placement. The surgeon performs the renal access. The procedure involves only one stone and the patient has Medicare insurance.
Coding: Begin with code 50080 with modifier LT Left side appended. Report the renal access using 50432-52. The placement of the nephrostomy tube is included in 50080. The antegrade placement of the ureteral stent is also included in the work of 50080 and not separately billable.
Don’t add modifier 51 Multiple procedures because this is a Medicare patient. Medicare and many non-Medicare payers do not require 51. If your payer does, however, add modifier 51 to 50432-52 to ensure payment for the secondary procedure.