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MP 7.01.30 Percutaneous Nephrostolithotomy and Lithotripsy for Kidney Stones

Medical Policy
Section
Surgery
Original Policy Date
3/31/96
Last Review Status/Date
Reviewed by consensus/3:2003
Issue
3:2003
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

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.


Policy

Percutaneous nephrostolithotomy and lithotripsy are considered medically necessary for treating upper urinary tract kidney stones that are symptomatic and cannot be managed conservatively.


Policy Guidelines

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.


Benefit Application

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.


Rationale

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:

– Calculi
 
– Kidney
 
– Lithotripsy
 
– Percutaneous

Research was limited to English-language journals on humans.

See also:

TEC Evaluation and Coverage 1989: p. 112
 
Extracorporeal Shock Wave Lithotripsy for Kidney Stones. See Surgery Section: policy No. 7.01.10

 

Codes

Number

Description

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 
HCPCS  No code 
Type of Service  Surgery/Radiology 
Place of Service  Inpatient
 
Outpatient
 


Index

Lithotripsy, percutaneous, for kidney stones
Nephrostolithotomy for kidney stones
Percutaneous lithotripsy for kidney stones


Policy History

Date Action Reason
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


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