A nephrectomy is a surgical procedure involving the partial or complete removal of one kidney. It may be performed to treat malignancy, severe trauma, nonfunctioning kidneys, congenital abnormalities, or to procure a kidney for transplantation. From a medicalâcoding perspective, nephrectomy documentation must clarify: Extent (partial vs. total) Approach (open, laparoscopic, robotic) Indication (tumor, obstruction, infection, donation) Laterality (right, left) Additional procedures (lymphadenectomy, adrenalectomy, ureterectomy) These distinctions directly affect CPT and ICDâ10âPCS code selection. Nephrectomy is the surgical removal of a kidney, performed to treat kidney cancer, severe kidney damage, non-functioning kidneys, or to harvest a healthy kidney from a donor for transplantation. The term derives from the Greek nephros (kidney) and -ektomia (a cutting out), dating to 1880.
nephr-/nephro-: From Greek nephros meaning âkidney,â which traces back to Proto-Indo-European negwhro- (kidney)
-ectomy: From Greek -ektomia meaning âa cutting out of,â derived from ektemnein (âto cut outâ), combining ek (âoutâ) + temnein (âto cutâ)
Nephrâ â Greek nephros (νξĎĎĎĎ), meaning âkidneyâ
âectomy â Greek ektomÄ, meaning âcutting outâ or âexcisionâ
Nephrectomy literally means âcutting out the kidney.â
There are two main types for treating diseased kidneys
Partial nephrectomy (nephron-sparing surgery): Removes only the diseased or injured portion of the kidney while preserving healthy tissue, typically for tumors under 4 cm
Radical nephrectomy: Removes the entire kidney along with the surrounding fatty tissue, the ureter section, adrenal gland, and sometimes regional lymph nodes
Bilateral nephrectomy: Removal of both kidneys simultaneouslyâ
Surgical Approaches
The procedure can be performed through
Open surgery: Through a side or midline incision in the abdomen
Laparoscopic surgery: Using 3-4 small incisions (5-10 mm) with instruments and a camera
Single-port laparoscopy: Advanced technique through one incision in the navel
Documentation Clues for Coders
Look for phrases such as:
âKidney removedâ
âRadical excisionâ
âPartial resection of renal massâ
âGerotaâs fascia removedâ
âAdrenal gland taken en blocâ
âSpecimen sent to pathologyâ
âLymph nodes dissectedâ
âWarm ischemia timeâ (common in partial nephrectomy)
These help determine extent, approach, and bundled vs. separate procedures.
Coderâs Notes
Partial vs. total nephrectomy changes CPT/PCS codes significantly.
Radical nephrectomy may include adrenalectomy or lymphadenectomyâdocumentation must specify.
Approach matters: open, laparoscopic, robotic, or converted.
Laterality is essential for ICDâ10âCM and PCS.
For living donor nephrectomy, coding rules differ from oncologic or traumatic indications.
Check for concurrent procedures: ureterectomy, tumor thrombectomy, nephrolithotomy, nephropexy.