|MP 7.01.30||Percutaneous Nephrostolithotomy and Lithotripsy for Kidney Stones|
|Original Policy Date
|Last Review Status/Date
Reviewed by consensus/3:2003
|Return to Medical Policy Index|
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Percutaneous nephrostolithotomy (PCN) is an invasive procedure for removing upper urinary tract stones by means of forceps or wire basket devices. Percutaneous lithotripsy (PCL) is often used to break up large kidney stones to a more manageable size. A nephrostomy tract is first established by using a needle, catheter, dilators, and a nephrostomy tube under fluoroscopic guidance. After this has been accomplished, an endoscope is used to visualize the treatment area while lithotripsy instruments are inserted into the nephrostomy tube to break up the kidney stone.
Stone fragments are removed by catheter suction, forceps, or a small basket; smaller fragments are sometimes left to pass spontaneously. General or local anesthesia may be appropriate.
Percutaneous nephrostolithotomy and lithotripsy are considered medically necessary for treating upper urinary tract kidney stones that are symptomatic and cannot be managed conservatively.
Suitable stones for PCN/PCL therapy are:
- stones that cannot be fragmented by Extracorporeal Shock Wave Lithotripsy or ESWL treatment failures;
- stones that are impacted in the ureter;
- cystine stones;
- upper urinary tract stones when urinary diversions or obstructions are present;
- stones greater than 3 cm, which require debulking prior to ESWL; and
- contraindications to ESWL.
PCN/PCL may be used as an alternative or an adjunct to ESWL for stones in the 2- to 3-cm range.
BlueCard/National Account Issues
Percutaneous nephrostolithotomy may be performed in two stages, on different days, as follows:
Stage 1—Creation of nephrostomy tract and placement of tube to access stone; and
Stage 2—Disruption of stone and removal of fragments.
With complex stones, adjunctive procedures may be required in some cases (e.g., ESWL or mechanical removal), which may or may not necessitate the creation of a second percutaneous tract.
This procedure is performed as a team effort by a surgeon and radiologist.
A search of literature was completed through the MEDLINE database for the period of January 1992 through October 1995. The search strategy focused on references containing the following Medical Subject Headings:
Research was limited to English-language journals on humans.
TEC Evaluation and Coverage 1989: p. 112
Extracorporeal Shock Wave Lithotripsy for Kidney Stones. See Surgery Section: policy No. 7.01.10
|CPT||50080||Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction, up to 2 cm|
|50081||Over 2 cm|
|50395||Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous|
|74475, 74480, 74485||Radiologic supervision and interpretation code range|
|76000, 76001||Fluoroscopic guidance code range|
|ICD-9 Procedure||55.03||Percutaneous nephrostomy without fragmentation|
|55.04||Percutaneous nephrostomy with fragmentation|
|ICD-9 Diagnosis||592.0||Calculus of kidney|
|592.1||Calculus of ureter|
|Type of Service||Surgery/Radiology|
|Place of Service||Inpatient
Lithotripsy, percutaneous, for kidney stones
Nephrostolithotomy for kidney stones
Percutaneous lithotripsy for kidney stones
|03/31/96||Add to Surgery section||New policy|
|04/15/02||Replace policy||Policy reviewed without literature review; new review date only|
|10/9/03||Replace policy||Policy reviewed by consensus without literature review; no changes in policy; no further review scheduled|