© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 50386 involves the removal of an internally dwelling ureteral stent using a transurethral approach, specifically employing a snare or capture device. This method is performed without the aid of cystoscopy, which is a procedure that typically allows for direct visualization of the bladder and urethra. Instead, fluoroscopic guidance is utilized to ensure accurate placement and removal of the stent. A ureteral stent is a flexible tube, comparable in size to a strand of spaghetti, designed to maintain the patency of the ureter, facilitating the drainage of urine from the kidney to the bladder, particularly in instances of obstruction or blockage. The stent is generally intended for temporary use, remaining in place until the underlying obstruction is resolved, which may take several weeks to months. During the procedure, a catheter is inserted into the bladder, and contrast material is injected to enhance visualization of the urinary tract. A guidewire is then maneuvered into the bladder, allowing for the replacement of the initial catheter with a larger one. The snare or capture device is advanced to grasp the distal pigtail of the ureteral stent, enabling its removal into the bladder and urethra. Following this, a guidewire is introduced through the stent and advanced into the renal pelvis under fluoroscopic guidance. The stent is subsequently extracted, and a catheter is placed over the guidewire. Additional contrast is injected, the catheter is removed, and a new stent is positioned appropriately within the urinary tract. The correct placement of the stent is confirmed through fluoroscopy, and X-ray images are obtained to document its accurate positioning. It is important to note that if the ureteral stent is removed without being replaced, the specific code to use is 50386.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 50386 is indicated for the removal of an internally dwelling ureteral stent in cases where there is a need to alleviate obstruction or blockage in the urinary tract. The following conditions may warrant this procedure:
The procedure for the removal of an internally dwelling ureteral stent via CPT® Code 50386 involves several detailed steps to ensure successful extraction and, if necessary, replacement of the stent. The process begins with the insertion of a catheter into the bladder, where contrast material is injected to provide clear visualization of the urinary tract. Following this, a guidewire is advanced into the bladder, allowing for the initial catheter to be replaced with a larger catheter that can accommodate the snare or capture device. The snare or capture device is then carefully introduced and advanced to the distal pigtail portion of the ureteral stent located in the bladder. Once the stent is grasped, it is gently pulled into the bladder and urethra until it is fully exposed. At this point, a guidewire is introduced through the stent and advanced into the renal pelvis, utilizing fluoroscopic guidance to ensure accurate placement. The stent is then removed, and a catheter is advanced over the guidewire to facilitate the next steps. Additional contrast is injected to confirm the position of the catheter, which is subsequently removed. If a new stent is to be placed, it is passed over the guidewire and positioned with the proximal pigtail in the renal pelvis and the distal pigtail in the bladder. Finally, the guidewire is removed, and the correct positioning of the stent is confirmed through fluoroscopy, with X-ray images obtained to document its accurate placement.
After the completion of the procedure, patients may be monitored for any immediate complications or adverse reactions. It is essential to assess the patient's recovery and ensure that there are no signs of infection or other complications related to the stent removal. Patients may be advised to maintain adequate hydration and report any unusual symptoms, such as pain, fever, or changes in urinary patterns. Follow-up appointments may be scheduled to evaluate the effectiveness of the procedure and to determine if further interventions are necessary. Additionally, if a new stent has been placed, monitoring for proper function and positioning will be crucial in the subsequent days and weeks following the procedure.
| Short Descr | REMOVE STENT VIA TRANSURETH | Medium Descr | REMOVE INT DWELL URETERAL STENT TRANSURETHRAL | Long Descr | Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | 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) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | T-Packaged Codes | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 111 - Other non-OR therapeutic procedures of urinary tract |
This is a primary code that can be used with these additional add-on codes.
| 50606 | Addon Code MPFS Status: Active Code APC N ASC N1 Endoluminal biopsy of ureter and/or renal pelvis, non-endoscopic, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) | 50705 | Addon Code MPFS Status: Active Code APC N ASC N1 Ureteral embolization or occlusion, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) | 50706 | Addon Code MPFS Status: Active Code APC N ASC N1 Balloon dilation, ureteral stricture, including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) |
| 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. | RT | Right side (used to identify procedures performed on the right side of the body) | 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. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 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.) | 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) | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 2008-01-01 | Added | First appearance in code book in 2008. |
Get instant expert-level medical coding assistance.