Urology Coding Q&A: CPT 50080 and 50081

I have a question about CPT codes 50080 and 50081. I found your wonderful article previously published on this topic.¹ The lay description of CPT codes 50080 and 50081 indicates that the provider is making an incision through the skin to create the access. However, we have a case where the patient came in and had the nephrolithotomy while already having a nephrostomy tube in place. All the other components of CPT code 50080 were performed. Would you agree that modifier -52 would be appropriate if the initial access was through a previously placed nephrostomy opening?

Jonathan Rubenstein, MD

To help answer this question, we should first refer to the other recent question about these procedures. As noted there, the descriptors and work of CPT codes 50080 and 50081 were updated. The descriptors currently state the following:

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 a single location of kidney or renal pelvis, nonbranching stones)

50081: Complex (eg, stone[s] > 2 cm, branching stones, stones in multiple locations, ureter stones, complicated anatomy)

(Do not report 50080 or 50081 in conjunction with 50430, 50431, 50433, 50434, or 50435 if performed on the same side)

(For establishment of nephrostomy without nephrolithotomy, see 50040, 50432, 50433, and 52334)

Mark Painter

(For dilation of an existing percutaneous access for an endourologic procedure, use 50436)

(For dilation of an existing percutaneous access for an endourologic procedure with new access into the collecting system, use 50437; for additional new access into the kidney, use 50437 for each new access that is dilated for an endourologic procedure)

(For removal of stone without lithotripsy, use 50561)

(For cystourethroscopy with insertion of ureteral guidewire through the kidney to establish a retrograde percutaneous nephrostomy, use 52334)

As seen in the descriptor itself and in the reporting instructions, it is clearly stated that “for dilation of an existing percutaneous access for an endourologic procedure, use 50436.” That means it is appropriate to report CPT code 50436 for dilation of an existing tract (eg, a nephrostomy tube is already in place) at the time of performing a nephrolithotomy. We are wondering whether the lay description that was referenced in your question above was that of the original 50080 and 50081 codes before they were updated.

As per the previous answer, it is important to remember 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.

As we all know, Medicare rules do not always follow CPT directives. The same is true in this case. As described already, the NCCI considers codes 50436 and 50437 to be bundled into codes 50080 and 50081 despite all the descriptions and instructions for correct use described clearly in the CPT codebook. Therefore, reporting either 50436 or 50437 in conjunction with either 50080 or 50081 will require appending modifier -59 or -XU to be accurately processed and paid by Medicare and most private payers.

Reference

1. Rubenstein J, Painter M. How to bill for PCNL using existing and new access. Urology Times. September 22, 2023. Accessed December 16, 2024. https://www.urologytimes.com/view/how-to-bill-for-pcnl-using-existing-and-new-access

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

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.