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Question: A 54-year-old patient presented to the emergency department (ED) with severe lower abdominal pain and blood in their urine. A CT urogram was performed, first without contrast and then with contrast material. The imaging exam revealed a 2 cm stone in the left kidney. The urologist performed a percutaneous nephrolithotomy to remove the stone. The patient was diagnosed with a kidney stone, prescribed pain medication, and discharged.

How do we report the procedures?

Wyoming Subscriber

Answer: First, you’ll assign 50080 (Percutaneous nephrolithotomy or pyelolithotomy, lithotripsy, stone extraction, antegrade ureteroscopy, antegrade stent placement and nephrostomy tube placement, when performed, including imaging guidance; simple (eg, stone[s] up to 2 cm in single location of kidney or renal pelvis, nonbranching stones)) appended with modifier LT (Left side) to report the nephrolithotomy.

Next, you’ll use 74178 (Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions) to report the CT urogram procedure. This diagnostic imaging exam was performed to determine the source of the patient’s abdominal pain.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC