Percutaneous nephrostomy (PCN) is one of the common procedures that medical billing and coding outsourcing companies help urologists and radiologists report. The procedure involves placement of a catheter through skin of the back or flank into the kidney to drain urine. PCN can be done under flouroscopy, ultrasound (USG) or computed tomography guidance.

PCN may be performed for various reasons, the most common being to relieve an obstructed urinary system. Up to 85 to 90% of all nephrostomy placements are performed to drain an obstructed renal unit. The procedure allows decompression of the obstructed system and provides drainage in an acutely obstructed, infected kidney.  Indications for percutaneous nephrostomy include urine diversion, access to the collecting system, stone treatment, and diagnosis of the obstruction. PCN is also indicated for therapeutic interventions such as direct infusion of substances for dissolving stones, chemotherapy, and antibiotic and antifungal therapy. It permits specimen collection, and creates a route for instillation of antibiotics.

A comprehensive understanding of PCN codes and how to use them is necessary to ensure accurate documentation and billing for optimal reimbursement. In 2019, renal pelvic catheter procedures have been bundled to include all imaging guidance and radiological supervision and interpretation in a single code.

New and Revised CPT Codes

Nephrostomy tract dilation can be performed using balloon dilation, metal telescopic dilation, or Amplatz serial dilation. The new renal pelvic codes that came into effect in 2019 are intended to provide reimbursement for the extra time and work involved in endourologic tract dilation via balloon dilation or serial dilators.  The code changes, which include one deletion, are as follows:

  • Deleted: CPT code 50395 (Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous) has been deleted.

The American Medical Association (AMA) CPT Editorial Panel deleted CPT code 50395 to overcome the potential confusion and overlap with CPT code 50432 Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (e.g., ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (www.community.auanet.org)

  • New: To replace 50395, two new CPT codes were introduced for dilation of existing tract, including radiological supervision and interpretation:

50436 Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (e.g., ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, with postprocedure tube placement, when performed

50437 Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (e.g., ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, with postprocedure tube placement, when performed.

Other Percutaneous Endourologic Procedure CPT Codes

  • Note: Both 50436 and 50437 include all imaging guidance, and all associated radiological supervision and interpretation, as well as post-procedure tube placement when it is performed.
  • Revised: 74485 Dilation of ureter(s) or urethra, radiological supervision and interpretation

74485 was revised to specify that the code applies only to the ureter(s) or urethra vs a nephrostomy tract

Nephrostomy has been removed from the descriptor for 74485.

Coding Percutaneous Endourologic Procedures with Percutaneous Nephrolithotomy (PCNL)

PCNL (percutaneous nephrolithotomy) is a minimally invasive method of removing kidney and ureteral stones that are too large (usually larger than 2 centimeters), too numerous, or too dense to be treated by extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy.

There are two CPT codes to report Percutaneous Endourologic Procedures with Percutaneous Nephrolithotomy (PCNL):

  • 50080 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction < 2 cm
  • 50081 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction > 2 cm

Since initial access to the kidney is not included in the descriptors of codes 50080 or 50081, a separate code should be used to describe this extra work. A www.community.auanet.org report provides the following guidelines on this matter:

  • New codes 50436 and 50437 should not be used with the percutaneous nephrolithotomy codes 50080 or 50081 if performed by the same provider at the same time.
  • CPT code 50432 Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (e.g., ultrasound and/or fluoroscopy) and all associated radiologic supervision and interpretation should be used to describe the initial access if performed by the same provider.
  • In the case of “tubeless” procedure (no nephrostomy tube remains after the case) the 52 Reduced servicesmodifier should be appended when reporting CPT 50432.
  • CPT code 50432 should be used if the interventional radiologist places the initial nephrostomy tube, whether in the operating suite or in the radiology suite.
  • New access into the renal collecting system may be essential following percutaneous dilation of an existing tract. In this case, the surgeon places a percutaneous access needle through the skin of the back or flank and into the posterior renal calyces. Ultrasound or fluoroscopic guidance is used to pass the catheter or nephrostomy tube through the needle and into the renal calyx and intrarenal collecting system. The needle is then withdrawn. CPT code 50437 should be used to report this procedure.
  • To receive full reimbursement, the urologist does not need to report modifier 52 with CPT code 50437 since the descriptor for dilation states “when performed”.

Other Percutaneous Endourologic Procedure CPT Codes

To perform renal endoscopy, the dilation of the tract must be large enough to allow instruments to pass through. Urologists can report procedures that useendourologic instrumentation using renal endoscopy CPT codes 50551-50562 (Urology Place):

50551-Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service

50553 – with ureteral catheterization, with or without dilation of ureter

50555 – with biopsy;

50557 – with fulguration and/or incision, with or without biopsy;

50561 – with removal of foreign body or calculus; and

50562 – with resection of tumor

CPT code 50436 should be reported along with the procedure code if the urologist performs the dilation and a nephrostomy tube or access already exists. CPT code 50437 must be reported if the urologist creates a new access as well as dilates the tract for the surgeon.

Accurate documentation is a prerequisite for the medical coding company to assign the correct CPT codes. With the  increased specificity of the new CPT codes, the urologist/radiologist who performs the procedure needs to specifically and accurately document the presence or absence of access prior to the procedure, any new access created, the laterality, procedure performed, etc. Knowledgeable about local insurer rules, including bundling and modifiers, reliable medical billing service providers can help urologists and radiologists report procedures correctly for reimbursement purposes.