© Copyright 2025 American Medical Association. All rights reserved.
Nephrolithotomy is a surgical procedure specifically designed for the removal of a renal calculus, commonly known as a kidney stone. This open surgical technique involves making a direct incision in the skin over the kidney, allowing the surgeon to access the renal area effectively. The procedure begins with the dissection of soft tissues to reach the kidney, followed by the incision of Gerota's fascia, which is the connective tissue surrounding the kidney. During the operation, the surgeon carefully identifies and controls the blood vessels by placing loops around them to prevent excessive bleeding. Once the kidney is adequately exposed, a visual examination is conducted to locate the calculus. An incision is then made directly in the kidney at the site of the stone, allowing for its removal. The calculus is subsequently sent to a laboratory for analysis, which is reportable separately. After the stone is extracted, drains may be placed as necessary to facilitate fluid drainage. The procedure concludes with the closure of Gerota's fascia, removal of the vessel loops, and layered closure of the skin incision. This comprehensive approach ensures that the renal calculus is effectively removed while minimizing complications and promoting recovery.
© Copyright 2025 Coding Ahead. All rights reserved.
The nephrolithotomy procedure is indicated for patients presenting with renal calculi, which may cause significant symptoms or complications. The following conditions warrant the performance of this surgical intervention:
The nephrolithotomy procedure involves several critical steps to ensure the successful removal of the renal calculus:
After the nephrolithotomy procedure, patients are typically monitored for any signs of complications, such as bleeding or infection. Post-operative care may include pain management, hydration, and monitoring of kidney function. Patients may also require follow-up appointments to assess recovery and to discuss any further management of kidney stones, if necessary. The expected recovery time can vary based on individual patient factors and the extent of the surgery, but most patients can anticipate a gradual return to normal activities within a few weeks.
| Short Descr | NL REMOVAL CALCULUS | Medium Descr | NEPHROLITHOTOMY REMOVAL CALCULUS | Long Descr | Nephrolithotomy; removal of calculus | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 103 - Nephrotomy and nephrostomy |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2023-01-01 | Note | Short and medium descriptions changed. |
| Pre-1990 | Added | Code added. |