Urinary and Male Genital Systems List

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Urinary and Male Genital Systems
Chapter Topics
Urinary System
Male Genital System


Learning Objectives
After completing this chapter you should be able to
1

Understand the format and codes of the Urinary System subsection

2

Review the subheadings and categories of the Urinary System subsection

3

Report services with Urinary System codes

4

Understand the format and codes of the Male Genital System subsection

5

Review the subheadings and categories of the Male Genital System subsection

6

Report services with Male Genital System codes

URINARY SYSTEM

The Urinary System subsection (50010-53899) of the CPT manual is arranged anatomically by the subheadings of kidney, ureter, bladder, and urethra (Fig

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24-1), with category codes arranged by procedure (i

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, incision, excision, introduction, repair)

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A wide range of terminology is used in the subsection

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The Glossary at the back of this book includes many of the terms that you will encounter in the CPT manual

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Always be certain you know the meaning of all the words in the code description before you assign a code

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Kidney
The first subheading in the Urinary subsection is Kidney (50010-50593)

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Incision

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The Incision codes (50010-50135) are assigned to report exploration, nephrostomy, drainage, nephrolithotomy, and pyelotomy services

Renal exploration is a procedure performed if the cause of a patient's condition is unknown

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For example, surgical exploration of an injured kidney when the patient is clinically unstable and appears to be having renal blood loss

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Access for the exploration procedure is from the side (flank)

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Note that a parenthetical statement preceding 50010 indicates "For retroperitoneal exploration, abscess, tumor, or cyst, see 49010, 49060, 49203-49205," which are Digestive System codes

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Code 49010 reports an exploration of the retroperitoneum

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The term retroperitoneal refers to that area located behind (retro to) the peritoneum (lines the abdominal walls and covers most of the organs) that is located in the abdominal cavity

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The retroperitoneal space may be accessed by means of an abdominal incision

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When coding an exploration of the retroperitoneal space, be careful to determine the exact anatomical location(s) explored to report the correct services because there are many organ systems located in the abdominal cavity

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For example, the kidney is located in the retroperitoneal space

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If only the kidney was explored, report the service with the Urinary System code 50010

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if the retroperitoneal area was explored, report the service with the Digestive System code 49010, exploration of retroperitoneal area

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FIGURE

24-1 The four subheadings of the Urinary System subsection in the CPT manual are: Kidney, Ureter, Bladder, and Urethra

Renal pelvis
Kidney
Ureters
Bladder
Urethra
Meatus


CODING SHOT
Code 50021 has the symbol next to it to indicate that conscious (moderate) sedation is included with the procedure and not reported separately

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If a procedure begins as an exploratory procedure but becomes a definitive or corrective procedure, such as repair of a lacerated kidney, only the definitive procedure is reported

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The exploration is considered a diagnostic procedure that is bundled into the definitive procedure when both are performed during the same operative session

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Open drainage of a perirenal or renal abscess (50020) reports the drainage of a kidney abscess or the surrounding kidney tissue

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If the drainage was of a retroperitoneal abscess, the service would be reported with the Digestive System code 49060 that reports an open drainage of a retroperitoneal abscess

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Again, the exact location of the abscess is the critical factor when assigning the abscess drainage code

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The renal abscess can also be accessed percutaneously, in which case the service would be reported with 50021

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When performing a percutaneous access to the kidney, fluoroscopy, ultrasound, or computer tomography may be used for guidance of the needle placement and is reported separately with 75989

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A nephrostomy is a procedure used to decompress the renal system by means of the insertion of a catheter into the kidney while leaving the other end of the catheter outside the body to temporarily drain the kidney

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The renal collecting system may be obstructed by a calculus or a defect of the renal pelvis or ureter

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Code 50040 reports incisional placement of a drainage tube that involves incision into the renal pelvis (pyelotomy)

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The physician then inserts a catheter into the kidney with the other end carried to the skin surface and sutured in place on the flank

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A nephrotomy is exploration of the inside of the kidney

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During this exploration (50045), no definitive procedure is performed

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If a definitive procedure is performed the exploration is bundled into the definitive procedure

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For example, if the surgeon began a procedure as an exploration to determine the cause of urinary obstruction and identified a renal calculus (kidney stone) and removed the calculus, the procedure no longer would
be an exploration

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The procedure would be reported with 50060, kidney stone removal (nephrolithotomy)

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The surgeon may also perform a renal endoscopy at the same time as the nephrotomy (such as, to place stents or perform some other type of repair procedure), and the endoscopy is reported separately with a code from range 50570-50580 (Endoscopy, kidney)

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Nephrolithotomy procedures include removal of calculus (50060), secondary surgical operation for calculus (50065), procedures complicated by congenital kidney abnormality (50070), and removal of a staghorn calculus (50075)

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The staghorn calculus (Fig

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24-2) is shaped like a deer antler and can become large and create extensive obstruction

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If the calculus involves the renal pelvis and at least two calyces, it is classified as a staghorn calculus

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These types of stones account for about 30% of stones reported and are usually associated with urinary infections

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With a staghorn, a nephrolithotomy may be performed after extracorporeal shock wave lithotripsy (ESWL), which fragments the stones (50590)

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ESWL used to be performed with a machine in which the patient was submersed in a fluid

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Newer machines do not require submersion, rather the patient is placed on an x-ray table, and a water-filled cushion is placed under the patient's back (Fig

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The procedure is performed under general




anesthesia in an operating room with a built-in ESWL machine

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The shock waves are targeted to the stones by means of x-ray and pulverize the stones with repeated shocks

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Usually, the particles subsequently pass through the urinary tract

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Percutaneous nephrolithotomy (nephrolithotripsy) is a more invasive method of treating kidney stones and usually is performed with ultrasound

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An incision is made over the kidney, a probe is inserted, and shock waves pulverize the stone

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Electrohydraulic or mechanical lithotripsy may be used instead of shock waves, but the use of shock waves is the most common method

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A tiny basket may also be attached to a probe that is passed into the kidney and the stones removed

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Because the stone fragments of a staghorn are so large, they may not pass through the urinary system spontaneously, and an open or percutaneous procedure may need to be performed to remove the fragments

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The lithotripsy is reported separately (50590 lithotripsy or 52353 cystourethroscope with lithotripsy)

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F I G U R E
2 4 - 2
Large staghorn calculus inside the kidney filling the pelvis and calyceal system

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Kidney calculus
Renal cortex
Staghorn calculus
Large staghorn calculus resembles deer antler
X-ray

Percutaneous nephrostolithotomy (PCNL) or a pyelostolithotomy is a procedure to remove kidney stones

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In this procedure, entry is through the patient's back

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The procedure is reported based on the size of the stone removed (50080, to 2 cm

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50081, 2 cm)

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Internal lithotripsy is included in 50080 and 50081 and is not reported separately

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External lithotripsy is not included in the codes and can be reported in addition to 50080 and 50081

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but remember to attach modifier -51 to the lesser procedure

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The procedure is performed with fluoroscopic guidance that is reported separately with 76000 for the radiologist or 76001 for the radiologist who assists a nonradiological physician

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Excision

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There are Excision codes in the Kidney subheading for biopsy, nephrectomy (removal of the kidney), and removal of a cyst

The biopsy codes (50200, 50205) are based on the approach, either percutaneous (through the skin) or by surgical exposure of the kidney

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A nephrectomy is the removal of a kidney, either partial or radical (total)

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A radical nephrectomy includes removal of the fascia and surrounding fatty tissue, regional lymph nodes, and the adrenal gland

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The nephrectomy codes (50220-50240) are based on the complexity and extent of the procedure

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Nephrectomies can also be performed by means of a laparoscope (50543, 50545-50548), based on whether the procedure was partial, radical, or donor, and whether the procedure included a partial or total ureterectomy

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Ablation is the cutting away or erosion of tissue

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Code 50250 reports ablation of a kidney lesion by means of cryosurgery (use of subfreezing temperatures) and is usually performed with ultrasonic guidance

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If used, the ultrasonic guidance is not reported separately because it is included in the code description

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Monitoring is also included in the code

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The surgeon accesses the kidney through an incision and inserts a cryosurgical probe into the lesion

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The cryosurgical machine is turned on, and subfreezing temperature is delivered to the lesion (Fig

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The area is brought back to above freezing, and the treatment is applied again

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At times, more than two cycles are applied to ensure the lesion is ablated

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This procedure can also be performed percutaneously (50593) or by use of a laparoscope (50542)

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Renal Transplantation

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Allotransplantation is the transfer of tissue or an organ between two people who are not related (genetically different)

Autotransplantation is transfer of tissue from one part of a person's body to another part of that person's body, also known as autograft or autotransplant

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A surgeon may perform a renal autotransplant to reposition the kidney, which may be necessary when the kidney has been severely damaged from trauma or disease

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A renal autotransplantation is reported with 50380

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Backbench work is the work involved in preparation for the transplant surgery and includes:
n

Open organ retrieval from a deceased (50300) or living (50320) donor

laparoscopic organ retrieval from a living (50547) donor

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n

Standard preparation based on deceased (50323) or living (50325) donor

As a part of this preparation the surgeon may perform additional surgery on the organ, such as venous, arterial, or ureteral anastomosis (50327-50329)

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n

Allotransplantation service reported with 50360 (without nephrectomy) or 50365 (with nephrectomy) with modifier -50 added for a bilateral procedure

If backbench procedures were performed, those services would be reported in addition to the transplantation service with modifier -51 added to indicate multiple procedures

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CODING SHOT
If the recipient requires a nephrectomy, the procedure is reported separately with 50340 and with modifier -50 for a bilateral procedure

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Introduction

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Introduction category codes in the Kidney subheading are for aspiration, catheters, injections for radiography, guides, and tube changes

There are also extensive notes within the category

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Codes in the range 50382-50389 are percutaneous, transurethral, or externally accessible procedures that report removal and/or replacement of renal stents and tubes

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These stents are not renal artery stents but are ureteral stents that are placed through the renal pelvis

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The codes only report a unilateral procedure, so if a bilateral procedure was performed, add modifier -50

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Imaging guidance is used for the codes in this range and is included in the code description, so do not report the guidance separately

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If imaging guidance was not used for removal without replacement of an externally accessible ureteral stent, you would report the removal with an E/M code

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Approximately half of the population over age 50 has renal cysts that are asymptomatic (no symptoms) and are often only discovered as an incidental finding on ultrasound or computed tomography

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When these cysts are symptomatic, percutaneous aspiration or injection may be performed

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The procedure is performed by use of local anesthetic and on an outpatient basis

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A sclerosing agent (such as alcohol) may be injected into the cyst

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The code description for 50390 indicates "aspiration and/or injection," which means if both an aspiration and injection are performed during the same operative session, 50390 is reported only one time

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Image guidance is not included in the code description, so any guidance used is reported separately

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Repair

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Repair category codes (50400-50540) include plastic surgery (pyeloplasty), suturing (nephrorrhaphy), and closure of fistula

Pyeloplasty is a surgical procedure for an obstruction of the ureteropelvic junction (UPJ), which connects the renal pelvis to the ureter (Fig

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Usually, this is a congenital condition, but it may also be an acquired condition

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If an obstruction occurs the urine will not drain, which results in dilatation of the collecting system and enlargement of the renal pelvis (hydronephrosis)

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The goal of a pyeloplasty is to remove the obstruction and repair the renal pelvis (Fig

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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)

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A complicated pyeloplasty (50405) includes all of the procedures in the simple pyeloplasty, as indicated by the placement of the semicolon in 50400

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(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

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) 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

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A calycoplasty is repair of the calyx (the cup-shaped structure) of the kidney

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FIGURE

24-5
Ureteropelvic junction (UPJ) is the place at which the ureter joins the kidney at the renal pelvis

Cortex
Medulla
Parenchyma
Calyx
Hilum
Renal vessels
Renal pelvis
Ureter
Capsule
Pelvis of kidney
Ureteropelvic junction
Ureter
Perirenal fat


Closures of nephrocutaneous, pyelocutaneous, or nephrovisceral fistulas (abnormal openings) are reported with codes from the 50520-50526 range

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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

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

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

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Laparoscopy

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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

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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

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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

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

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For example, 50555 reports a renal endoscopy through an established nephrostomy/pyelostomy, and 50574 reports the same endoscopic biopsy but not through a nephrostomy/ pyelostomy

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

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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

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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 Locations

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You will locate the kidney codes in the CPT manual index under "Kidney"

they are subtermed primarily by category (e

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See More

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