Tactical Understanding of Urinary Therapeutic Procedure Coding

Tactical Understanding of Urinary Therapeutic Procedure Coding

Urinary therapeutic procedure coding is inherently complex; each code comes with its own nuances and areas of potential confusion. Given the multitude of codes involved, our experts have identified urinary therapeutic procedures as an area of caution. This area has undergone significant change: Some, but not all, of the previous therapeutic genitourinary (GU) procedure codes have been deleted and replaced with complete codes that include diagnostic nephrostogram or ureterogram, when performed. Coders must carefully read the code descriptions to determine when multiple codes may be reported. Let’s review some key tips for success.

Cracking Coding Basics

Traditionally, “catheter” and “stent” have been used somewhat interchangeably. However, for  the purposes of these codes, “stent” is used for a completely internal device, while “catheter” indicates that a portion remains outside of the body. As is the case with many codes, clear documentation is crucial, so that the appropriate code may be chosen, regardless of which term the physician uses. For instance, the physician may document placement of a nephroureteral stent that has one end in the bladder and the other connected to a drainage bag. Despite use of the term “stent,” this should be coded as a nephroureteral catheter placement, not a stent placement.

50390 Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous
74470 Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and interpretation

Understand that codes 50390 and 74470 may be assigned for aspiration of a renal cyst. Do not report code 50390 for an antegrade pyelogram. Instead, when appropriate, assign code 50430 for true diagnostic antegrade pyelography.

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

Report code 50432 for placement of a percutaneous nephrostomy tube into the kidney for drainage. This code includes access, catheter positioning and repositioning, diagnostic imaging (if performed), imaging guidance, and supervision and interpretation. Coders should be cautious not to report a 70000 code for imaging guidance.

50433 Placement of nephroureteral 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, new access

Report code 50433 for placement of a nephroureteral drainage catheter that combines a ureteral catheter and nephrostomy catheter into a single catheter for external and/or internal drainage; this is applicable when the service is performed through a new access. Code 50433 encompasses the access, catheter positioning, injections of contrast (including diagnostic studies, if performed), imaging guidance, and supervision and interpretation.

Analyzing 50434 and 50435
50434 Convert nephrostomy catheter to nephroureteral 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, via pre-existing nephrostomy tract

Report code 50434 for conversion of a previously placed nephrostomy catheter (to kidney only) to a nephroureteral drainage catheter (through the kidney into the ureter or bladder). This code fully details diagnostic studies, if performed, nephrostomy catheter removal and replacement with a nephroureteral catheter, injections of contrast, imaging, and supervision and interpretation.

50435 Exchange 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

Report code 50435 for exchange of a previously placed nephrostomy tube with a new nephrostomy tube. This code includes diagnostic studies (if performed), removal of the existing nephrostomy tube and replacement with a new tube, imaging guidance, and supervision and interpretation. If a previously placed nephrostomy catheter is removed, a ureteral stent is placed, and a new nephrostomy is placed, report code 50693 alone instead of 50435 and 50693.

Under the circumstances that a patient presents for a nephrostomy tube exchange, but the tube has fallen out at home, code this as an exchange (50435) — provided the existing nephrostomy tract is patent and the new nephrostomy tube is easily introduced. If, however, the existing tract is closed and the physician needs to reestablish tract access to place a new nephrostomy tube, code this as a new placement (50432).

Relevant Replacements for 50395
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
50437 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; including new access into the renal collecting system

Code 50395 was deleted, and two new codes were added to report access for subsequent endourologic procedures. Report code 50436 when there is an existing nephrostomy tube or nephroureteral catheter, and the radiologist enlarges that tract to allow the surgeon to use larger instruments during an endourologic procedure, such as a kidney stone removal. When there is no existing nephrostomy tube or nephroureteral catheter and the radiologist must create the access, as well as dilating the tract for the surgeon, report code 50437 instead of 50436. Do not report code 74485 with codes 50436 or 50437.

Be aware that neither of these codes is reported for normal dilation of the tract for placement of a nephrostomy tube, nephroureteral catheter. Normal, basic dilation is included in the placement codes 50432, 50433, or 52334. Use unlisted code 53899 if the radiologist is asked to create a new access without dilation to place a wire only into the bladder for a subsequent endourologic procedure.

These are not all the essential coding tips and rationale for basic interventional radiology knowledge and urinary system coding. As service volumes rebound and every dollar of reimbursement counts more than ever, it’s imperative to make sure your CPT® coding is correct and compliant. Master more IR coding topics, and break down the complexity with our expert-infused Genitourinary Interventional Radiology Coding webcast. This webcast is an essential training tool for both audio and visual learners.

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