Urology Coding Alert

Hint: The work for code 50432 already includes a nephrostogram.

If a patient has kidney or ureteral stones that your urologist can’t remove with extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy, he may have to perform a percutaneous nephrostolithotomy (PCNL) for the stone removal.

Follow five handy steps to make sure you keep your PCNL claims in tip-top shape.

Step 1: Know Which Procedure Codes to Report

If your urologist performs a PCNL, you can choose from the following CPT^® codes:

• 50080 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm)
• 50081 (… over 2 cm)

Remember: When you are choosing between codes 50080 and 50081, you must check the medical documentation and choose the appropriate code based upon the size of the largest single stone your urologist treats, not the total stone burden, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York. The work associated with both 50080 and 50081 includes the nephrostomy tract dilation, internal lithotripsy, anti-grade stenting, and basket extraction, as per the code descriptors, and recently added nephrostomy tube placement at the end of the procedure.

Code 50432: If your urologist performs renal access, you should report 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). You would append modifier 52 (Reduced services) to code 50432 to indicate that the code does not include separate placement of a nephrostomy tube at the conclusion of the procedure.

Step 2: Remember Associated Imaging

If your urologist performed a nephrostogram to help guide the PCNL procedure and did not perform or report renal access with 50432, then you can look to code 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 code 50431 (… existing access).

However, you must check the documentation to verify that your urologist did perform the nephrostogram before you report 50430 or 50431 because not every urologist will perform those procedures with a PCNL. Also, remember that codes 50430-50432 include the radiological supervision and interpretation, as per the code descriptors. So, if your urologist performs the interpretation, you cannot report this service separately.

Caution: The work for code 50432 already includes a nephrostogram, which is why you cannot report this procedure separately.

Step 3: Don’t Report Nephrostomy Tube Placement Separately

When your urologist performs a PCNL, he may place a nephrostomy tube at the end of the procedure. Since placement is already included in codes 50080 and 50081, you should not report it separately. However, if your urologist places the tube at the beginning of the PCNL, you can report code 50432 appended with modifier 52 because of the overlapping of services.

Step 4: Include Renal Endoscopy

If you check the medical documentation and verify that your urologist also performed an incision of an infundibular stricture during the PCNL, you can report code 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) for this additional work.

Step 5: Include Other Procedures Performed During PCNL

Your urologist may also perform other procedures during a PCNL. These 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) indicating that the urologist only interpreted the radiological films but does not own the radiological equipment owned by the hospital.
• 50961 (Ureteral endoscopy through established ureter­ostomy, with or without irrigation, instillation, or uretero­pyelography, exclusive of radiologic service; with removal of foreign body or calculus)-XS (Separate structure…)

Putting it Together With an Example

According to the medical documentation, your urologist performed a cystoscopy with left retrograde pyelogram, left ureteral stent placement, left percutaneous access, left PCML, nephrostomy tube placement at the beginning of the procedure, and ureteral catheter placement. The urologist fragmented a 1 cm size stone during the procedure.

You should report the following codes on your claim:

• 52005 and 74420-26 (Urography, retrograde, with or without KUB) (Professional component) for the cystoscopy with left retrograde pyelogram interpretation
• 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)) for the cystoscopy with stent placement
• 50432-52 for the left percutaneous access
• 50080 for the PCNL