Why can’t CPT 50436 and 50437 be used when performing percutaneous nephrolithotomy?

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"For several reasons, the percutaneous nephrolithotomy codes needed to be revised, as the language of the descriptor and what was included and not included was confusing and ambiguous," write Jonathan Rubenstein, MD, and Mark Painter.

Why can’t the CPT 50436 and 50437 be used when performing percutaneous nephrolithotomy?

A few years ago, new CPT codes were created to describe the work of dilating a nephrostomy tube tract to a size large enough to accommodate endoscopic instrumentation. This work was sometimes performed by an interventional radiologist, but there was no CPT code to capture that work. These new CPT codes were 50436 (dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance [eg, ultrasound and/or fluoroscopy] and all associated radiological supervision and interpretation, with postprocedure tube placement, when performed) and CPT code 50437 (including new access into the renal collecting system).

CPT codes 50080 (percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction up to 2 cm) and 50081 (…>2 cm) both include the work of dilation (the code descriptor states that these codes should be used “with or without dilation”), so one cannot code for dilation separately, as that work has already been captured.

For several reasons, the percutaneous nephrolithotomy codes needed to be revised, as the language of the descriptor and what was included and not included was confusing and ambiguous. Starting January 1, the descriptors will now be 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]) and 50081 (…complex [eg, stone(s)>2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy).

As one can see, the outdated terms nephrostolithotomy and pyelostolithotomy were replaced with the more commonly used nephrolithotomy and pyelolithotomy. For clarification, the more granular term antegrade ureteroscopy was added to clarify that the valued work encompasses everything performed in an antegrade approach such as antegrade ureteroscopy and antegrade stent placement (if performed) along with nephrostomy tube placement and imaging guidance. Dilation of the tract was removed from the descriptor because of the overlap with CPT codes 50436 and 50437 so that dilation procedures (dilation without and with new access, respectively) are reported separately if performed by the same surgeon at the same setting or if medically necessary retrograde services performed on the same date are not included in the code description.

Note, as well, the pivot from stone size as the differentiation between codes 50080 and 50081 to the terms simple and complex, with examples in the following parentheticals. The new codes now mirror the bladder stone codes. The parentheticals 50080 (…simple [eg, stone(s) up to 2 cm in single location of kidney or renal pelvis, nonbranching stones]) and 50081 (…complex [eg, stone(s)>2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy])provide examples to indicate what would be considered simple or complex. Note that in addition to stone size, the examples include differentiation for stone location, stone structure, anatomic variation, and reference to stones in multiple vs single locations. Based on these code description changes, coders and physicians may wish to review the new descriptions and discuss possible ways of clearly communicating complex vs simple cases in the operative note.

The code changes are accompanied by noticeable decreases in work relative value units and remibursement for 2023. The change in what codes can be reported in addition to 50080 and 50081 will offset some these decreases; however, the impact on each physician based on these changes will vary based on current coding patterns and procedures performed.

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.