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The procedure described by CPT® Code 50553 involves renal endoscopy performed through an already established nephrostomy or pyelostomy. This procedure is utilized to examine the kidney and ureter for any abnormalities, such as obstructions or stenosis. The process begins with the removal of the external drainage bag from the nephrostomy or pyelostomy tube, allowing access to the internal structures. A guidewire is then advanced through the tube, facilitating the removal of the nephrostomy tube itself. Following this, a series of dilators are utilized to expand the tract, enabling the insertion of a renal endoscope. This endoscope allows for a direct visual examination of the kidney. During the procedure, sterile saline or other solutions may be used for irrigation, and diagnostic or therapeutic solutions can be instilled into the kidney. Additionally, contrast material may be used for ureteropyelography, although this specific service is excluded from the CPT® Code 50553 description. A key component of this procedure is ureteral catheterization, which involves advancing a ureteral catheter through the endoscope into the ureter for further examination. If any stenosis is detected, a balloon-tipped catheter can be introduced to the affected area and inflated to dilate the stenotic region. The procedure concludes with the removal of all instruments, replacement of the nephrostomy tube, and reattachment of the external drainage bag, ensuring that the patient’s drainage system is restored and functioning properly.
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The procedure described by CPT® Code 50553 is indicated for various conditions related to the renal system. These include:
The procedure involves several critical steps to ensure effective renal endoscopy through an established nephrostomy or pyelostomy:
Post-procedure care following CPT® Code 50553 involves monitoring the patient for any immediate complications related to the endoscopy. Patients may require observation for signs of infection, bleeding, or any adverse reactions to the procedures performed. It is essential to ensure that the nephrostomy tube is functioning correctly and that the external drainage bag is securely attached. Patients may also receive instructions regarding activity restrictions and signs to watch for that would necessitate immediate medical attention. Follow-up appointments may be scheduled to assess the effectiveness of the procedure and to monitor the patient's renal function.
| Short Descr | KIDNEY ENDOSCOPY | Medium Descr | RENAL NDSC NEPHROST W/URETERAL CATH W/WO DILA | Long Descr | Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter | 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) | 1 - Statutory 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 | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8I - Endoscopy - other | MUE | 1 | CCS Clinical Classification | 100 - Endoscopy and endoscopic biopsy of the urinary tract |
| 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). | LT | Left side (used to identify procedures performed on the left 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). | 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. | 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.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | RT | Right side (used to identify procedures performed on the right side of the body) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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