Urology Coding Alert

Kidney stones gather no reimbursement - unless you know your modifiers and code descriptors

When a patient returns to the operating room soon after a previous urologic procedure, it can be confusing to coders. If the new session involves multiple procedures, it gets even more vexing. No matter how many coding guides, supplements and resources you collect, this may be a coding dilemma that just won't fit neatly into the scenarios described in CPT or presented in the coding seminar your entire department just attended.

Michelle O'Dell, billing manager for the Panama City Urological Center in Panama City, Fla., recently faced - and conquered - the following case. Scenario: A week ago, a male patient, age 64, underwent percutaneous nephrolithotomy (PCNL) through a midcalyceal puncture. The urologist dislodged a stone into an upper pole calyx that he could not access at the time of the initial procedure. He discharged the patient home in stable condition with a nephrostomy tube in place.

This week, the patient returned to the operating room for a second-look renal endoscopy through the already established nephrostomy tube tract. With fluoroscopic imaging, the urologist was able to see the stone but still could not access it through the previous puncture site and decided to restick the patient. He used a spinal needle to access the calyx and passed a Glidewire through the spinal sheath and down the renal pelvis to the ureter. He dilated the tract and passed an ultrasonic lithotripsy probe through a nephroscope to remove the stone. He then used a flexible cystoscope to reach down and remove a lower pole stone with a stone basket.

After finishing the nephrolithotomy, the urologist turned the patient over and performed a cystoscopic examination. Using a stone grasper, he grabbed and removed a bladder stone that he had identified last week.

The operative report lists the following procedures:
   percutaneous nephrostomy through an upper pole calyx
   percutaneous ultrasonic lithotripsy
   placement of nephrostomy tube
   fluoroscopy guidance
   cystoscopy and removal of bladder stone.

Boldly Code for Both Access and PCNL To report the procedure, O'Dell settled on these CPT codes:

CPT Code 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting or basket extraction; over 2 cm) for the nephrostolithotomy and stone removal (the percutaneous nephrostomy and ultrasonic lithotripsy). The code includes dilation, internal lithotripsy and basket removal, all of which the urologist performed in this case. Because the stone removed from the kidney was more than 2 cm, O'Dell says, she chose that code rather than  50080 (... up to 2 cm).

Code 50395-51 (Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous; multiple procedures) for the percutaneous access. Modifier -51indicates that 50081is the primary [...]