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Basics about Antegrade Nephrostogram

A percutaneous antegrade pyelogram is performed by placing a needle into the collecting system of a kidney with injection of contrast and image documentation. The kidney can be accessed under a variety of guidance methods. This procedure is usually performed prior to more complex renal interventions and is rarely performed as a stand-alone procedure. Different procedures codes are used for coding new and existing access for Nephrostogram procedures. CPT code 50430 and 50431 are reported for injection procedure for antegrade nephrostogram. Both the procedure codes includes the imaging guidance and the associated radiological supervision and interpretation.

Code description of CPT code 50430 and 50431

Their is a small difference between coding procedure code 50430 and 50431. Only new access injection procedures for nephrostogram should be reported with 50430 cpt code, while already existing access injection procedure should be reported with procedure code 50431. Below is the detail code description for these exams.

50430 – Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; new access

50431 ; existing access

Do remember, Code 50430 describes an antegrade nephrostogram via a new access. This could be with a needle or catheter, which is removed at the end of the procedure.

Nephrostogram (CPT code 50431) involves injection of contrast into a newly placed or pre-existing kidney drainage tube (nephrostomy), ileal conduit, or ureterostomy. Evaluation is performed under fluoroscopic guidance with documentation of images.

When to use CPT code 50430 and 50431

In order to use a code for diagnostic nephrostogram, documentation of findings in the renal collecting system must be described, and there must be a clinical indication to perform the diagnostic imaging procedure (e.g., leaking catheter, purulent drainage), not just “routine” tube check.

CPT code 50430 is bundled with codes 50432-50435 (nephrostomy or nephroureteral catheter procedures) and 50693-50695 (ureteral catheter procedures).

Use code 50431 once per renal collecting system. When performed on both right and left renal tubes, assign a -50 modifier to the procedure code .

For a complete diagnostic antegrade nephrostogram via a new access, use CPT code 50430. This procedure code includes imaging guidance, placement of a needle or catheter into the renal collecting system, contrast injection, diagnostic imaging, and also the removal of the needle or catheter at the end of procedure.

When to use CPT code 50390 and 50432

CPT code 50390 describes percutaneous needle access to a renal cyst and includes aspiration of fluid out of a cyst and injection of contrast if done. For placement of Nephrostomy catheter, we have a separate code 50432. Below is the complete code description of procedure codes.

50390 – Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous (percutaneous renal cyst study)

50432 – Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation

If both diagnostic antegrade pyelogram and a nephrostomy tube placement is performed in same setting, the only submit the percutaneous nephrostomy tube placement procedure code 50432.

Injection procedure through a newly placed or pre-existing catheter in a renal calyx or the renal pelvis (50430, 50431 respectively) is bundled with a nephrostomy tube placement (50432) or change (50435).

Always use CPT code 50390 for injection procedure through a newly placed needle or catheter into a renal cyst. This procedure codes is only for aspiration of renal cyst. For renal pelvis injection or accesss, use procedure code 50430.

CPT codes for Nephrostogram tube check and exchange

Nephrostomy tube check involves injection of the tube with contrast and documentation of the findings. The exchange portion of the exam occurs when a wire is placed through the existing tube and the tube is removed, followed by placement of a new tube into the kidney over the wire.

50435– Change of nephrostomy or pyelostomy tube (RS&I is bundled)

50389 -Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent)

Coding for percutaneous nephrolithotomy CPT code 50080 and 50081

The description of CPT codes 50080 and 50081 includes dilation of the tract large enough for endourologic instrumentation, stenting and tube placement at the end of the case if performed. Therefore, the new CPT codes 50436 and 50437 should not be used with 50080 or 50081 if performed by the same provider at the same time. However, initial access to the kidney is not included in the description or work of 50080 or 50081, and therefore a separate code should be used to describe this extra work. Since CPT 50395 has been deleted, CPT code 50432 should be used to describe the initial access if performed by the same provider. If the procedure is “tubeless” (no nephrostomy tube remains after the case), a -52 modifier should be applied to CPT 50432. If an interventional radiologist places the initial nephrostomy tube, whether in the operating suite or in the radiology suite, then they should use CPT code 50432. If the interventional radiologist performs access and also dilates the tract themselves and leaves a large sheath in the patient such as may be done in an operating room, the interventional radiologist should report CPT code 50437. The urologist does not need a 52 Reduced services modifier on the code. The descriptor for dilation states “if performed” so the urologist does not need to perform the dilation to maintain full reimbursement.

Coding for other percutaneous endourologic procedures

Codes that may be performed by a urologist that use endourologic instrumentation are CPT codes:

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.

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”

References:

https://community.auanet.org/blogs/policy-brief/2018/12/04/how-to-use-the-new-percutaneous-dilation-codes

Best Coding Guide for Nephrostogram Procedures