• The goal of a pyeloplasty is to remove the obstruction and repair the renal   pelvis. As a part of the repair, a nephropexy (surgical fixation of mobile kidney), nephrostomy (a passageway from the kidney to exterior of the body), pyelostomy (a passageway between the renal pelvis and the exterior of the body), and ureteral splinting are included in the codes   for a simple pyeloplasty (50400). 

  • A complicated pyeloplasty (50405) includes all of the procedures in the simple pyeloplasty, as indicated by the placement of the semicolon in 50400. (Note that the semicolon is after the term “splinting,” which means that all the terms that precede the semicolon are included in the code description for the indented code 50405.)

 

• In addition to all the procedures in the simple pyeloplasty, the complicated pyeloplasty is more difficult, because the procedure may include repair of a congenital kidney abnormality (which can be an extensive procedure), further plastic repair of the pelvis of the kidney, repair of a solitary kidney (patient only has one kidney), or a calycoplasty. A calycoplasty is repair of the calyx (the cup-shaped structure) of the kidney.

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• Closures of nephrocutaneous, pyelocutaneous, or nephrovisceral fistulas (abnormal openings) are reported with codes from the 50520- 50526 range. Code 50520 reports the closure of a fistula between the renal pelvis and the exterior of the body or of the kidney and the exterior. 

 

• Codes 50525 and 50526 report closure of a fistula between the kidney and another organ, such as the kidney and the bladder. 

 

• The approach to close the fistula may be abdominal (50525) or thoracic (50526).

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LAPAROSCOPY (50541 – 50580)

 

• The Laparoscopy codes (50541-50549) report ablation of renal cysts (50541) or lesions (50542).

 

• Open cryosurgical ablation of renal tumors is reported with 50250, and percutaneous ablation is reported with 50593

 

• Laparoscopic nephrectomies and pyeloplasty are also reported with codes from the Laparoscopy category and are based on the extent of the procedure.

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ENDOSCOPY (50551 – 50593)

• Endoscopy codes (50551-50580) are frequently reported for kidney procedures, because these types of procedures are less invasive than the open procedures and are often performed in an outpatient setting. 

 

• Renal endoscopies may be performed by means of an established connection between the kidney and the exterior of the body. 

 

• The codes in the Endoscopy category are divided into those procedures performed through an established nephrostomy or pyelostomy and those that are not. 

 

• The codes are further divided based on the reason for the procedure: ureteral catheterization, biopsy, fulguration, or foreign body/calculus removal or tumor resection. 

 

• The code descriptions in the Endoscopy category code descriptions state “exclusive of radiologic service,” which means that the radiologic services are reported in addition to the endoscopic procedures. If, for example, a biopsy (50555) is performed with ultrasound, you would report the biopsy procedure in addition to the ultrasound.

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KIDNEY INDEX LOOCATIONS

• You will locate the kidney codes in the CPT manual index under “Kidney”; they are subtermed primarily by category (e.g., insertion, excision, or repair). Another method of locating kidney codes in the CPT manual index is to reference the medical term for the procedure (e.g., nephrostomy or nephrotomy). 

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• Again, there are other index location methods; these are just a couple to help you get started locating the codes. The following kidney codes or code ranges are unilateral and require modifier -50 if the procedure was performed bilaterally: 

 

                50080-50081, 50120-50135           Incision

                50200-50230                                   Excision

                50320, 50340, 50360, 50365          Renal Transplantation

                50382-50390, 50432-50435           Introduction

                50545-50547, 50549                      Laparoscopy

                50551-50561, 50570-50580           Endoscopy

                50590, 50592                                  Other Procedures

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• The insurance company (third-party) payer may require reporting modifiers -RT and -LT rather than modifier -50. 

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URETER (50600 – 50980)

• The next subheading (50600-50980) in the Urinary System subsection is Ureter. 

• The codes are based on the procedure (i.e., incision, excision, introduction, repairs, laparoscopy, or endoscopy). 

• The ureter is the tube that leads from the kidney to the bladder and may be the site of an assortment of conditions, such as obstruction by calculus, cysts, or lesions in addition to reflux, congenital abnormalities, and fistulas. 

 

INCISION/BIOPSY (50600 – 50630)

• These codes report open procedures to explore or drain (50600), insert indwelling stent (50605), and removal of calculus (ureterolithotomy) based on the location of the calculus as upper third, middle third, or lower third of the ureter (50610-50630)

• The incisional procedures also have laparoscopic, endoscopic, and/or transvesical counterparts. 

• For example, to report a laparoscopic ureterolithotomy of the upper third of the ureter, report 50945, and for an incisional ureterolithotomy, report 50610. 

• It is very important to check the documentation for the method utilized for the procedure to ensure selection of the correct code.

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EXCISION (50650 – 50660)

• These codes report ureterectomy either with bladder cuff or a total excision.

 

• The bladder cuff is the tissue that connects the ureter to the bladder, and the excision of the bladder cuff is only reported if it is the only procedure performed during the surgical session

 

• A total ureterectomy may be performed by means of an abdominal, vaginal, or perineal approach or a combination of the three approaches. 

 

• Code 50660 includes all three approaches or a combination of approaches. This means that if two or three approaches were utilized, you still only report 50660 one time.

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INTRODUCTION (50684 – 50695)

• These codes include injection procedures, manometric studies, and change of tubes and/or stents. 

 

• Code 50684 reports an injection procedure performed through an indwelling catheter to determine the status of the renal collecting system. 

 

• The physician injects a contrast agent through the catheter and an x-ray is taken. The radiological supervision and interpretation is reported separately with 74425. 

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• Manometric studies (50686) are tests to measure kidney and ureter flow and pressure. 

  • The study is conducted by means of a machine (manometer) through an access site, which is connected to a ureterostomy or ureteral catheter filled with fluid. 

 

• A tube carrying sterile fluid is inserted through the access site and into the kidney or bladder and the area is flooded. The pressures and flow are then measured and recorded.

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REPAIR (50700 -50940)

• These codes includes ureteroplasty (plastic repair of the ureter), ureterolysis (freeing of fibrous tissue), ureteropyelostomy (connection of upper ureter to renal pelvis), ureterocalicostomy (connection of upper ureter to renal calyx), and ureteroureterostomy (bypass of obstructed ureter), in addition to numerous other procedures to repair the ureter.

 

LAPAROSCOPY (50945 – 50949)

• Laparoscopic ureter codes 50947 and 50948 report the placement of a ureteral stent, which may be performed in conjunction with or without cystoscopy. The stent is placed because of an obstruction of the ureterovesical junction (UVJ). The surgeon laparoscopically repositions the ureter on the bladder and then by means of the cystoscope places the ureteral stent.

 

ENDOSCOPY (50951 – 50980)

• These codes report procedures that are performed through an established stoma (ureterostomy, 50951-50961) or through an incision into the ureter (ureterotomy, 50970-50980). 

 

• The procedures conducted through a ureterostomy are similar to the types of procedures conducted through a nephrostomy (e.g., 50551-50562, biopsy, catheterization, irrigation, and instillation). 

 

• The endoscopy procedures are for irrigation, instillation, catheterization, biopsy, fulguration, and foreign body or calculus removal. The procedures often utilize radiological services, but these services are reported separately. Note that the stand-alone code descriptions in the category (50951, 50970) indicate that the service is “exclusive of radiologic service,” meaning that you report those services in addition to the procedure. 

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• When a ureterocystography is performed, the physician injects a radioactive contrast material through a catheter inserted into the bladder via the urethra or through a previously established stoma.

  • The injection procedure is reported in addition to the primary procedure. 

 

• In addition to the primary and injection procedures, you also report the radiological supervision and interpretation with a Radiology code.

 

• For example, 74425 reports retrograde urography. Retrograde urography is performed by injecting contrast directly into the lower end of the system, and the contrast flows backwards through the system allowing for visualization of the tract. 

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BLADDER (51020 – 52700)

 

• Contains codes not only for the usual services, such as incision and excision, but also for some unique services such as urodynamics and procedures performed on the prostate.

 

INCISION (51020 – 51080)

 

• Cystotomy (51020-51045) is often performed to fulgurate (use of electric current), insert radioactive material, or cryosurgically to destroy a lesion. 

• In addition, the procedure is used for drainage, placement of catheter/stent, or a cystolithotomy (removal of calculus). 

• A cystolithotomy reported with 51050 is one in which an incision is made in the skin and into the bladder. 

  • The physician removes the calculus through the incision but does not excise the bladder neck.

  • A transvesical ureterolithotomy described in 51060 is a similar procedure to 51050, but the calculus is removed through an incision in the bladder and the ureter. 

  • The ureter calculus is removed by basket extract through an incision in 51065,                                              and in some cases the calculus is first fragmented by ultrasound or electrohydraulic means. 

  • Electrohydraulic fragmentation is the use of a probe containing two electrodes that are applied,                        one on each side of the calculus. Electrical current is then directed through the electrodes, which fragments the calculus

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REMOVAL (51100 – 51102)

• Aspiration of urine from the bladder may be accomplished by means of needle, trocar (a sharply pointed surgical instrument), or intracatheter (plastic tube with a needle on the end). 

 

• A suprapubic (above the pubic bone) catheter may also be inserted during the aspiration service (51102). Aspirations are often performed by means of imaging guidance, which is reported separately. If imaging guidance is used, report the guidance separately with 76942, 77002, or 77012.

 

EXCISION (51500 – 51597)

• A urachal cyst is between the umbilicus and bladder dome and is often diagnosed in young children when the cyst becomes infected.

  • A urachal sinus is a congenital abnormality in which prenatal tissue remains, causes drainage to the umbilicus, and results in infection. 

  • The excision of a urachal cyst or sinus is reported with 51500 and may or may not include umbilical hernia repair

• Cystotomies and cystectomies (51520-51596) are performed for a variety of reasons, such as excision of a portion of or all of the bladder, repair of a ureterocele, or to replant a ureter into the bladder. The codes are divided based on the extent of the procedure. If the procedure is performed transurethrally, such as a bladder resection, codes from the Transurethral Surgery category (52204-52318) would be reported. 

 

• Pelvic exenteration (51597) is also known as total pelvic exenteration (TPE) and is the removal of the pelvic organs and adjacent structures due to malignancy. 

• If TPE is performed due to gynecologic malignancy, report the service with the Female Genital system code 58240. 

 

• A hysterectomy may be performed with 51597, but the initial and primary reason the procedure is being performed is for other than a gynecological malignancy.

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INTRODUCTION (51600 – 51720)

• The injection procedures reported with codes 51600-51610 are for urethrocystography (x-ray of lower urinary tract, also known as a cystourethroscopy). 

 

• The radiological supervision and interpretation are reported in addition to the injection procedure. Note that the parenthetical statements after each of the injection codes direct the coder to the correct radiology code(s)

 

• Insertion of bladder catheters may be non-indwelling (51701) or temporary indwelling (51702, 51703). 

  • The non-indwelling catheter is the type that is inserted into the urethra and manipulated into the bladder to drain residual urine. 

  • The temporary indwelling procedure can be a simple catheterization (such as with a Foley) or a complicated catheterization due to an anatomical anomaly. 

  • Catheter fracturing may occur, for example, when a patient pulls the catheter out while the balloon is still inflated. This is a rare complication and does not describe the insertion but rather why it was necessary to reinsert another catheter. 

• Instillation is a procedure that is performed for bladder cancer. An anticarcinogenic agent is introduced into the bladder by means of a catheter. 

• For example, immunotherapy is the instillation of a nonactive tuberculosis agent into the bladder. 

 

• The agent is retained in the bladder for a period of time (such as 1 hour) with the patient in a supine position. 

 

• The agent is then drained, and the treatment is concluded. A series of these instillations is performed in a course of treatment. Code 51720 reports the instillation as well as the retention time and drainage.

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URODYNAMICS (51725 – 51798)

• Urodynamics pertains to the motion and flow of urine. Urinary tract flow can be obstructed by renal calculi, narrowing (stricture) of the ureter, cysts, and so forth. 

 

• The procedures in the Urodynamics subheading (51725-51798) are to be conducted by or under the direct supervision of a physician, and all the instruments, equipment, supplies, and technical assistance necessary to conduct the procedure are bundled into the codes. 

 

• If the physician performs only the professional service (e.g., interpretation of the results), modifier -26 (professional component) is reported with the code to indicate that the technical portion of the service (performance of test or tests) was provided elsewhere. 

 

• For example, if a physician provides only the interpretation (-26) of a complex urethral pressure profile (UPP) (51727), report only the professional component of the service as 51727-26.

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REPAIR & LAPAROSCOPY (51800 – 51980, 51990 – 51999)

• Repair procedures (51800-51980) include procedures such as cystoplasty (bladder repair), cystourethroplasty (bladder and urethra), vesicourethropexy/urethropexy (repair for urinary incontinence), and closure of fistulas. 

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ENDOSCOPY (52000 – 52010)

• There are codes (52000-52010) for bundled endoscopy procedures (i.e., cystoscopy, urethroscopy, and cystourethroscopy). The codes contain the primary procedure of a cystourethroscopy (endoscopic procedure to view the bladder and urethra) and minor related procedures performed at the same time.

• There are combination codes that include many components of a procedure bundled into one code. 

• Be careful to read each description in this category before assigning a code to be certain you have identified each component included in the code before you assign additional codes. 

 

• Many third-party payers, such as CMS, have lists of codes (edits) that cannot be reported with other codes. For example, 52000 (cystourethroscopy) cannot be reported with 51701 (catheterization), even though catheterization is not stated in the code description. You need to know not only the limitations set by the notes and codes in the CPT manual but also the limitations set by the third-party payer. 

 

• A cystourethroscopy is a diagnostic procedure to assess lower urinary tract symptoms (LUTS), such as incontinence or benign prostate hypertrophy (BPH). The procedure is reported only if it is performed as the only procedure during the operative session, because it is designated a separate procedure.

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TRANSURETHRAL SURGERY (52204 – 52356)

• Transurethral Surgery codes (52204-52355) are for the urethra/bladder (52204-52318) and ureter/pelvis (52320-52355). 

 

• Code 52204 reports a cystourethroscopy with biopsy and 52000 is also a cystourethroscopy. The difference is that 52000 is a diagnostic procedure only. No additional procedure was performed when reporting 52000. 

 

• When reporting 52204, a biopsy was performed, so the procedure was not only diagnostic but also a surgical procedure. 

• The procedure may have begun as a diagnostic procedure, but it progressed to a biopsy on identification of a lesion. The diagnostic procedure is then bundled into the surgical procedure and not reported separately.

 

• A transurethral resection of a bladder tumor (TURBT) is a procedure in which a bladder tumor is removed by fulguration (electric current) or excision. 

  • Note that the code descriptions 52234- 52240 contain multiple methods of removal of the bladder tumor, that is, “with fulguration (including cryosurgery or laser surgery) and/or resection.” 

 

• If any, or a combination of, these methods has been used to eradicate the tumor, you can assign a code based on the size of the bladder tumor. 

 

• The code description indicates the size as small (0.5-2.0 cm), medium (2.0-5.0 cm), and large (>5 cm). Code 52224 is a cystourethroscopy with fulguration or treatment of a minor (<o.5 cm) lesion(s). The lesion(s) are treated with fulguration (electrocautery), cryosurgery or a laser. 

 

• This procedure may or may not include a biopsy prior to eradication.

• The codes in the Ureter and Pelvis subsection (52320-52355) all include insertion and removal of temporary stents during the procedure, even though the code descriptions may not all state that fact.

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• Insertion of indwelling stents is reported separately with 52332-51 in addition to the primary procedure. 

• Code 52332 reports insertion of unilateral stents, so modifiers to indicate bilateral procedures were performed would also be needed; for example, 52332-51-50. 

 

• To report removal of indwelling stents, use 52310 (simple removal) or 52315 (complicated removal) with modifier -58 (staged or related procedure or service by same individual during the postoperative period). 

 

• It is a good idea to place a bracket next to codes 52310 and 52315 and write “-58” as a reminder of how to report these codes, because the direction for the use of this modifier is located in notes before code 52320.

 

VESICAL NECK & PROSTATE (52400 – 52700)

• The Vesical Neck and Prostate codes 52400-52700 contain codes to report cystourethroscopy and transurethral procedures. Many of these codes are reviewed in the Male Genital System information because many of these procedures are of the prostate with access through the urethra, such as 52450, transurethral incision of the prostate. 

• When the procedure is a transurethral resection of the bladder neck, report 52500. If a transurethral incision of the bladder neck is performed, report 52276 (Bladder, Urethrotomy). 

• The following bladder codes or code ranges are unilateral and require modifier -50 if the procedure was performed bilaterally:

  • 52320-52344, 52352-52355 - Ureter & Pelvis​

• The third-party payer may require reporting modifiers -RT and -LT rather than modifier -50.

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URETHRA (53000 – 53899)

• The subheading Urethra contains codes (53000-53899) for the usual procedures of incision, excision, and repair. 

• For endoscopic procedures of the urethra, refer to codes 52000-52700, which contain cystoscopy, urethroscopy, and cystourethroscopy procedures. 

 

• If the physician performs the injection procedure for radiology studies for examination of the urethra, report 51600-51610 based on the type of study being performed. 

• The radiological supervision and interpretation is reported separately with 74430 (cystography), 74450 (retrograde urethrocystography), or 74455 (voiding urethrocystography).

 

INCISION (53000 – 53085)

• A meatotomy is surgical incision of the meatus, which is the opening of the urethra to the outside of the body (urethral meatus). 

  • This procedure is often bundled into other more major procedures. Codes 53020 (except infant) and 53025 (infant) report a meatotomy if it is performed as a separate procedure. Because 53025 is specifically for infants, do not append modifier -63 (Procedure performed on infants less than 4 kg).

• The Skene’s glands are also known as the paraurethral or the lesser vestibular glands and are located on either side of the urethra. 

• These glands drain into the urethra near the meatus (urethral opening). When infected, the gland will become enlarged and tender and may require drainage or excision. Drainage of an abscess or cyst of the Skene’s glands is reported with 53060.  Excision of the Skene’s glands is reported with code 53270

 

EXCISION (53200 – 53275)

• These codes includes services such as biopsy, urethrectomy, lesion excision, fulguration, and marsupialization (creating a pouch).

• When the urethra is totally surgically removed (urethrectomy), the service is reported with 53210 for a female and 53215 for a male. 

• A urethrectomy involves removal of the urethra and creation of an opening from the bladder to the skin that is then used to drain urine. 

• The procedure would include removal of any tumors of the urethra. If the urethra was not removed and only the tumor was removed, report with 53220. The bulbourethral gland is also known as the Cowper’s gland and is a pair of glands about the size of a pea located beneath the prostate. These glands secrete a fluid that forms part of the semen and drains directly into the urethra. Excision of the bulbourethral gland is reported with 53250.

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REPAIR (53400 – 53520)

• A urethroplasty may be completed in one stage or two stages (53400- 53431). The choice of codes to report a urethroplasty is based on the number of stages and type of repair. Codes 53420 (first stage) and 53425 (second stage) report the two stages of an urethroplasty, and 53415 reports a one-stage urethroplasty.

 

• A tandem cuff or dual cuff is an artificial urinary sphincter (AUS) that is placed due to atrophy, disease, or defect of the urinary sphincter and reported with 53444. 

  • An artificial sphincter is inflatable and includes a pump, reservoir, and cuff, is inserted through a subpubic incision

  • The small switch in the scrotum can be manipulated to activate the pump and control  urinary continence. Codes 53446-53448 report the removal and/or replacement of an  AUS system, and 53449 reports repair of a previously placed system.

 

• Urethromeatoplasty is repair of the meatus and the urethra (53450, 53460)   and is performed to open and/or reconstruct the urethra. 

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MANIPULATION (53600 – 53665)

• The Manipulation category codes (53600-53665) are a bit different from those you have encountered previously. Manipulation is performed on the urethra (e.g., dilation or catheterization). 

 

• Dilation stretches or dilates a passage that has narrowed. The Dilation codes are based on initial or subsequent dilation of a male or female patient.

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***END OF NOTES***