Proper coding for percutaneous nephrolithotomy includes code 50081.
I have a question about 50080 and 50081. If the physician goes through the lower pole (existing access) and performs a nephrolithotomy of a stone larger than 2 cm, but cannot access a separate upper pole through that site and needs to create and dilate a new access, how would one report the service considering those 2 codes have a medically unlikely edit (MUE) of 1? Would it make sense to add a 22 modifier or is it all inclusive regardless of the sites?
Thank you for this excellent question. To begin, let’s delve into the scope of our percutaneous nephrolithotomy codes and the corresponding guidelines for reporting. As you may know, there have been recent revisions to the descriptors and reporting directives for Current Procedural Terminology (CPT) codes 50080 and 50081, effective January 2023. These codes are described as follows:
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)
50081: [C]omplex (eg, stone[s] > 2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy)
Furthermore, it’s important to note that the establishment of percutaneous access or the enlargement of the tract to facilitate the utilization of larger endoscopic instruments during stone removal procedures (reported with CPT codes 50436 or 50437) is not encompassed within the parameters of reporting CPT codes 50080 and 50081. Therefore, these procedures can be reported separately if they are performed. Consequently, in the context of performing a percutaneous nephrolithotomy, the dilation of an existing percutaneous access can be reported using CPT code 50436, whereas the dilation with creation of a new access into the collecting system can be reported using CPT code 50437. It’s worth highlighting that according to coding guidelines, in scenarios where there is the introduction of multiple new access points into the kidney, each instance of access dilation for endourologic procedures should be reported using code 50437.
The CPT codebook also outlines instructions for bilateral coding in the following manner: Report either CPT code 50080 or 50081 for each side (ie, for each kidney), irrespective of the number or size of stones or their respective locations. CPT code 50081 specifically encompasses the breaking and removal of “stones in multiple locations,” including that of separate stones in the kidney and in the ureter. Therefore, 1 unit of 50081 would be reported no matter how many stones and locations are treated in the same side (right or left) and no matter how many percutaneous accesses are needed to remove the stone burden. Note that in instances involving bilateral procedures (both the right and left kidneys are approached during one surgical encounter), modifier 50 would be used when reporting bilateral 50080 or bilateral 50081 procedures. According to CPT guidance, no modifier is needed if CPT code 50080 performed on one side and CPT code 50081 on the contralateral side.
As we all know, Medicare rules do not always follow CPT directives. The same is true in this case.
Therefore, in this case, if a lower pole stone was broken and removed after dilating a lower pole access, and an upper pole stonewas treated through a new upper pole access, it would be appropriate to report CPT codes 50081 for the stone removal, 50436-59 (or -XU) for dilation of the lower pole access, and 50437 -59 (or -XU) for dilation with new access of the upper pole access.
Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.
Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.