Some important changes were made to two existing urinary system procedural codes (CPT code 50080, 50081) for the CPT 2023 code set. The changes involved updating many terms commonly used in the past for urinary procedures that no longer reflect current clinical practice and resulted in new introductory guidelines, code descriptor revisions, and new parenthetical notes for codes 50080 and 50081 in the Urinary System subsection of the Surgery section. This article provides an overview of these changes and describes appropriate usage of the revised codes.

Urinary System

Incision

Nephrolithotomy is the surgical removal of stones from the kidney, and pyelolithotomy is the surgical removal of stones from the renal pelvis. This section of the guidelines refers to the removal of stones from the kidney or renal pelvis using a percutaneous antegrade approach. Breaking and removing stones is separate from accessing the kidney (ie, CPT code 50040, 50432, 50433, 52334), accessing the kidney with dilation of the tract to accommodate an endoscope used in an endourologic procedure (ie, CPT code 50437), or dilation of a previously established tract to accommodate an endoscope used in an endourologic procedure (ie, CPT code 50436). These procedures include the antegrade removal of stones in the calyces, renal pelvis, and/or ureter with the antegrade placement of catheters, stents, and tubes, but do not include retrograde placement of catheters, stents, and tubes.

CPT code 50080 describes nephrolithotomy or pyelolithotomy using a percutaneous antegrade approach with endoscopic instruments to break and remove kidney stones of 2 cm or smaller.

CPT code 50081 includes the elements of 50080, but it is reported for stones larger than 2 cm, branching, stones in multiple locations, ureteral stones, or in patients with complicated anatomy.

Creation of percutaneous access or dilation of the tract to accommodate large endoscopic instruments used in stone removals (50436, 50437) is not included in 50080, 50081, and may be reported separately, if performed. Codes 50080, 50081 include placement of any stents or drainage catheters placed in an antegrade manner that remain indwelling after the procedure.

Report one unit of CPT 50080 or 50081 per side (ie, per kidney), regardless of the number of stones broken and/or removed or locations of the stones. For bilateral procedure, report 50080, 50081 with modifier 50. When 50080 is performed on one side and 50081 is performed on the contralateral side, modifier 50 is not applicable. Placement of additional accesses, if needed, into the kidney, and removal of stones through other approaches (eg, open or retrograde) may be reported separately, if performed.

Report one unit of 50080 or 50081 per side (ie, per kidney), regardless of the number of stones broken and/or removed or locations of the stones. For bilateral procedure, report 50080, 50081 with modifier 50. When 50080 is performed on one side and 50081 is performed on the contralateral side, modifier 50 is not applicable. Placement of additional accesses, if needed, into the kidney, and removal of stones through other approaches (eg, open or retrograde) may be reported separately, if performed.

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 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)

(50080, 50081 may only be reported once per side. For bilateral procedure, report 50080, 50081 with modifier 50)

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

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

(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 kidney to establish a percutaneous nephrostomy, retrograde, use 52334)

Codes 50080 and 50081 were revised to align with current clinical practice and terminology and to appropriately describe the procedural work performed. Terms such as “nephrostolithotomy, pyelostolithotomy, endoscopy, stenting, basket extraction” are no longer used and have been replaced with “nephrolithotomy, pyelolithotomy, antegrade ureteroscopy, antegrade stent placement, stone extraction.” See Table 1 for terminology updates.

n addition to the terms updated above, the code descriptors were revised by removing “with or without…,” and replacing it with “. . . when performed,” to clarify that the other procedures do not need to be performed to report these codes without a modifier, and to clarify that these procedures should not be reported separately if performed. In addition, the term “dilation” was removed from the descriptor to clarify that dilating the endoscopic tract to a size large enough to accommodate endoscopic instruments for stone removal—with or without new access—is separate work and may be reported separately when performed.

The definitions of “simple” (50080) and “complex” (50081) procedures were also further clarified by adding granularity while retaining the stone-size measurement differentiator. A new exclusionary parenthetical note was added following code 50081 that precludes reporting codes 50430, 50431, 50433, 50434, and 50435 with codes 50080 and 50081, if the procedure is performed ipsilaterally (ie, same side). Note that both codes include imaging guidance.

If dilation of an existing percutaneous access is performed, it is reported with code 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. Dilating an existing percutaneous access with new access into the renal collecting system and additional new access into the kidney is reported with code 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. These instructions were also added as new parenthetical notes following codes 50436 and 50437.

Code 50080 describes surgical removal of stone(s) up to and including 2 cm from a single location of the kidney or renal pelvis, or for stones that do not branch from one location into other locations. Code 50081 describes a more complex service that involves removal of stone(s) larger than 2 cm, stones that branch into other locations, or stones in multiple locations including the ureter, or in patients with complicated anatomy. For reporting purposes, if the procedure represented by code 50080 or 50081 is performed on both kidneys at the same session (bilaterally), modifier 50, Bilateral Procedure, is appended to the single code.

When the simple procedure is performed in one kidney and the complex procedure is performed in the contralateral kidney or ureter, both codes are reported separately with either modifier 51, Multiple Procedures, or modifier 59, Distinct Procedural Service, or otherwise with modifier LT, Left side, or modifier RT, Right side, depending on individual third-party payer preference.

The following clinical examples and procedural descriptions reflect typical clinical scenarios for which these new codes would be appropriately reported.

Clinical Example (CPT code 50080)

A 68-year-old male with a 1.8-cm calculus in the lower pole of the kidney undergoes a percutaneous nephrolithotomy. [Note: Initial access and dilation are separately reported.]

Description of Procedure (CPT code 50080)

Insert a rigid nephroscope through the previously placed Amplatz sheath and identify the stone. Insert the handheld lithotripter through the nephroscope and fragment the stone as much as possible. Extract the fragments with grasping forceps and/or suction. Once the limits of rigid nephroscopy have been reached (due to angulation), insert a flexible nephroscope to access calyces inaccessible with the rigid nephroscope. Remove calyceal stones with a stone basket or fragment with a laser and then remove the fragments with a stone basket. Perform antegrade ureteroscopy to ascertain there are no fragments in the ureter. Pass the flexible ureteroscope through the access sheath into the calyx and into the renal pelvis. Identify the ureteropelvic junction and pass the ureteroscope through the junction and into the ureter.

Assess the entire length of the ureter for injury from passage of guidewires/catheters. Then withdraw the ureteroscope. At the completion of the nephrolithotomy, remove the nephroscope. During the entire procedure, the operating surgeon tracks the use of fluids and pressures in real time to ensure no fluid mismatch. Remove the Amplatz sheath. Obtain fluoroscopic images over the ipsilateral lung to ascertain there is no evidence of a pneumothorax or hydrothorax. Place a nephrostomy tube. Perform a nephrostogram to determine proper positioning of the nephrostomy tube.

Clinical Example (50081)

A 66-year-old male with a staghorn (branched) calculus filling the entire renal pelvis and most calyces undergoes a percutaneous nephrolithotomy. [Note: Initial access and dilation are separately reported.]

Description of Procedure (50081)

Insert a rigid nephroscope through the previously placed sheath and identify the large stone. Insert the handheld lithotripter through the nephroscope and fragment the stone as much as possible. Extract fragments with grasping forceps and/or suction. Once the limits of rigid nephroscopy have been reached (due to angulation), utilize additional nephrostomy access into the kidney in a similar fashion. Again, carry out rigid nephroscopy of calyceal and remaining renal pelvis stone. Once this is complete, insert a flexible nephroscope to access calyces inaccessible with the rigid nephroscope. Remove calyceal stones with a stone basket or fragment with a laser and then remove the fragments with a stone basket. Perform antegrade ureteroscopy to ascertain there are no fragments in the ureter. Pass the flexible ureteroscope through the access sheath into the calyx and into the renal pelvis. Identify the ureteropelvic junction and pass the ureteroscope through it into the ureter.

Assess the entire length of the ureter for injury from passage of guidewires/catheters. Assess the ureter for primary stones or stone fragments. Remove small fragments with a stone basket. For larger stones, pass a laser fiber and fragment the stone(s). Irrigate small fragments down the length of the ureter or remove with a stone basket. Once the ureter is deemed to be free of stone fragments, withdraw the ureteroscope. At the completion of the nephrolithotomy, remove the nephroscope. During the entire procedure the operating surgeon tracks the use of fluids and pressures in real time to ensure no fluid mismatch. Remove the Amplatz sheath. Obtain fluoroscopic images over the ipsilateral lung to ascertain there is no evidence of a pneumothorax or hydrothorax. Place a nephrostomy tube in each access. Perform a nephrostogram to ascertain proper positioning of the nephrostomy tube(s).

Reference : CPT assistant September month