A urologist in our clinic posed a question to our coding department regarding the use of 50437 with code 50080 or 50081. I am including recent chart documentation in hopes I can get a more definitive answer on what code should be billed in this particular circumstance. Our urologists are making the INITIAL percutaneous renal access to establish nephrostomy tract. He believes he should be using 50437 (and 50080), as he listed within his documentation below. *An interventional radiologist is NOT involved; all services are being done by the urologist.
In researching this, I have read from multiple sources that 50436/50437 should not be used with 50080/50081, if performed by the same provider at the same time. We have billed this coding combination before (50437 with 50081) and insurance has paid.
I am also wondering if he should be using 50432-52? The changes made in these codes in 2019 did not seem to make coding PCNLs easier, in my mind.
Any help on making this coding scenario more clear cut on which codes are correct to use below would be GREATLY appreciated. Again, he listed what codes he thought in his note. Thanks!
PROCEDURE PERFORMED:
SPECIMENS: Right renal stone.
FINDINGS:
PROCEDURE IN DETAIL: After being identified as the patient in preoperative holding, the patient was taken to the operating room. On the gurney, he was induced under general anesthetic and intubated. He was then moved to the operating table in the prone position with arms carefully positioned and legs on split positioner. Her back, perineum, and genitals were prepped and draped in usual sterile fashion. A time-out was performed to confirm the correct patient and procedure.
I passed a flexible cystoscope via the urethra into the bladder. The entire bladder was free of mucosal lesions. Identified the existing left ureteral stent. It was grasped and extracted through the meatus. A guidewire was passed through the scope up the right ureter under fluoroscopic guidance, moved alongside the large stone in the renal pelvis. I then removed the scope and over this wire, passed a 5-French open-ended catheter to the level of the stone. A 16-French catheter was placed alongside this ureteral catheter to gravity with 10 mL in the balloon.
I turned my attention to accessing the kidney. 10 mL of air was injected via the ureteral catheter to create an air nephrogram and the irrigation was attached to this catheter to create hydronephrosis. At 25 degrees lateral rotation, above the 12th rib, I passed an 18-gauge Chiba needle through a small skin nick into a posterior upper pole calyx. AP views confirmed depth. The stylette was removed and a rush of air, followed by clear irrigant, was obtained confirming location. A ZIPwire was passed through the needle down alongside the stone into the bladder. The ureteral catheter was withdrawn. The needle was removed. An 8-10 coaxial dilator was used to pass a stiff wire alongside the ZIPwire. I then dilated the nephrostomy tract with a 30-French NephroMax balloon and passed the sheath into the kidney.
A rigid nephroscope was then advanced through the sheath and I encountered the ovoid stone within the renal pelvis. The Trilogy Lithotripter wand was used to fragment and extract all pieces. Any remaining pieces removed with a tri-prong grasper. A flexible cystoscope was passed into the kidney and no fragments were remaining. Fluoroscopic view of the kidney was clear.
I then used a flexible scope to evaluate all calices and no residual stones were seen. Over the ZIPwire, I advanced a 6-French x 26 cm double-J stent which was noted to be in appropriate position following wire removal. Due to simple access incomplete stone clearance I elected to terminate the procedure without placing a nephrostomy tube. Skin was closed with interrupted horizontal mattress 3-0 nylon. Fluoroscopically the tubes are in appropriate location via antegrade nephrostogram. I then secured the drains and dressed the wound. She was transferred to the gurney in the supine position, taken to recovery in stable condition.
In researching this, I have read from multiple sources that 50436/50437 should not be used with 50080/50081, if performed by the same provider at the same time. We have billed this coding combination before (50437 with 50081) and insurance has paid.
I am also wondering if he should be using 50432-52? The changes made in these codes in 2019 did not seem to make coding PCNLs easier, in my mind.
Any help on making this coding scenario more clear cut on which codes are correct to use below would be GREATLY appreciated. Again, he listed what codes he thought in his note. Thanks!
PROCEDURE PERFORMED:
- Initial percutaneous renal access to establish nephrostomy tract (CPT 50437), left
- Percutaneous nephrostolithotomy, up to 2 cm, (CPT 50080), left
SPECIMENS: Right renal stone.
FINDINGS:
- First stick access to upper pole posterior calyx above 12th rib
- All stone fragments removed from kidney
- Simple access and complete stone clearance led to decision for no nephrostomy placement
PROCEDURE IN DETAIL: After being identified as the patient in preoperative holding, the patient was taken to the operating room. On the gurney, he was induced under general anesthetic and intubated. He was then moved to the operating table in the prone position with arms carefully positioned and legs on split positioner. Her back, perineum, and genitals were prepped and draped in usual sterile fashion. A time-out was performed to confirm the correct patient and procedure.
I passed a flexible cystoscope via the urethra into the bladder. The entire bladder was free of mucosal lesions. Identified the existing left ureteral stent. It was grasped and extracted through the meatus. A guidewire was passed through the scope up the right ureter under fluoroscopic guidance, moved alongside the large stone in the renal pelvis. I then removed the scope and over this wire, passed a 5-French open-ended catheter to the level of the stone. A 16-French catheter was placed alongside this ureteral catheter to gravity with 10 mL in the balloon.
I turned my attention to accessing the kidney. 10 mL of air was injected via the ureteral catheter to create an air nephrogram and the irrigation was attached to this catheter to create hydronephrosis. At 25 degrees lateral rotation, above the 12th rib, I passed an 18-gauge Chiba needle through a small skin nick into a posterior upper pole calyx. AP views confirmed depth. The stylette was removed and a rush of air, followed by clear irrigant, was obtained confirming location. A ZIPwire was passed through the needle down alongside the stone into the bladder. The ureteral catheter was withdrawn. The needle was removed. An 8-10 coaxial dilator was used to pass a stiff wire alongside the ZIPwire. I then dilated the nephrostomy tract with a 30-French NephroMax balloon and passed the sheath into the kidney.
A rigid nephroscope was then advanced through the sheath and I encountered the ovoid stone within the renal pelvis. The Trilogy Lithotripter wand was used to fragment and extract all pieces. Any remaining pieces removed with a tri-prong grasper. A flexible cystoscope was passed into the kidney and no fragments were remaining. Fluoroscopic view of the kidney was clear.
I then used a flexible scope to evaluate all calices and no residual stones were seen. Over the ZIPwire, I advanced a 6-French x 26 cm double-J stent which was noted to be in appropriate position following wire removal. Due to simple access incomplete stone clearance I elected to terminate the procedure without placing a nephrostomy tube. Skin was closed with interrupted horizontal mattress 3-0 nylon. Fluoroscopically the tubes are in appropriate location via antegrade nephrostogram. I then secured the drains and dressed the wound. She was transferred to the gurney in the supine position, taken to recovery in stable condition.