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50220

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😷CPT 50220: Nephrectomy, including partial ureterectomy

Short Definition

Open simple nephrectomy — surgical removal of an entire kidney with partial ureterectomy (proximal ureter) via any open surgical approach, including rib resection when necessary for exposure, without regional lymphadenectomy and without vena caval thrombectomy.

Full CPT Descriptor

nephrectomy, including partial ureterectomy, any open approach including rib resection

Long Clinical Definition

CPT 50220 describes a simple open nephrectomy — complete removal of the kidney and proximal portion of the ureter through an open incision. The term “simple” in this context refers to the scope of the procedure relative to a radical nephrectomy — it does not imply clinical ease. This is a major open abdominal or retroperitoneal surgical procedure requiring general anesthesia and inpatient hospitalization.

The key distinction between 50220 and its sibling codes is what is not included — no regional lymphadenectomy, no vena caval thrombectomy, and no requirement to remove Gerota’s fascia or the adrenal gland as part of the planned resection. The dissection in a simple nephrectomy is typically limited to:

  1. Complete mobilization and removal of the kidney.
  2. Ligation and division of the renal artery and vein.
  3. Division and removal of the proximal ureter (partial ureterectomy).
  4. Closure of the retroperitoneal or peritoneal space.

“Any open approach” in the CPT descriptor means all of the following are covered under 50220:

  • Flank incision — retroperitoneal approach; standard for most simple nephrectomies.
  • Anterior transperitoneal incision — midline or subcostal; used for larger kidneys or complex anatomy.
  • Thoracoabdominal incision — when upper-pole access requires entering the thorax.
  • Rib resection — explicitly included in the descriptor; do not separately bill rib resection when performed for exposure during 50220.

Note

“Including partial ureterectomy” means the proximal ureter is removed and is bundled into 50220 — do not separately bill for partial ureterectomy.

Inpatient Only Designation

CPT 50220 is designated as Medicare Inpatient Only — it cannot be billed on an outpatient hospital or ASC claim for Medicare beneficiaries. The procedure requires full inpatient hospital resources including:

  • General anesthesia.
  • Intraoperative monitoring.
  • Intensive post-operative nursing and pain management.
  • Minimum 2-4 day inpatient stay.

Note

Non-Medicare commercial payers may have different site-of-service policies — always verify payer-specific coverage before scheduling.

CPT Code Family — Open Nephrectomy Ladder

CPTDescriptorKey Distinguishing Feature
50220Nephrectomy, open, simple with partial ureterectomyNo LND, no thrombectomy, no prior surgery complications
50225Nephrectomy, open, complicatedPrevious surgery on same kidney increases complexity
50230Radical nephrectomy, open, with regional LND and/or IVC thrombectomyIncludes lymphadenectomy and/or IVC tumor thrombus removal
50234Radical nephrectomy with total ureterectomy and bladder cuff, transperitoneal, with LNDFull ureter + bladder cuff removed; one incision
50236Radical nephrectomy with total ureterectomyFull ureter removed; two separate incisions
50240Partial nephrectomy, openKidney preserved; portion removed (nephron-sparing)
50545Laparoscopic radical nephrectomyMinimally invasive; no LND
50546Laparoscopic radical nephrectomy with regional LNDMinimally invasive with lymphadenectomy
50548Laparoscopic nephrectomy with total ureterectomyMinimally invasive; full ureter removed

What Is Included in CPT 50220

All of the following are bundled into 50220 and must NOT be billed separately:

  • Complete mobilization and excision of the kidney.
  • Ligation, dissection, and division of the renal artery and vein.
  • Partial ureterectomy (proximal ureter removal to an appropriate distal level).
  • Rib resection if required for surgical exposure — explicitly included in the descriptor.
  • Routine intraoperative hemostasis, irrigation, and wound closure.
  • Placement of surgical drains (when standard part of procedure).
  • All routine post-operative E/M visits within the 90-day global period.
  • Suture and drain removal.

What Is NOT Included — Separately Reportable

ServiceCPTNotes
Total ureterectomy with bladder cuff50234 or 50236When entire ureter + bladder cuff removed — upcode to 50234/50236; do not add a ureterectomy code to 50220
Contralateral adrenalectomy60540If contralateral adrenal gland separately resected; ipsilateral adrenalectomy alone is debatable — see adrenalectomy nuance section
Regional lymphadenectomyNot separately billable with 50220LND performed at simple nephrectomy is bundled when limited; extensive retroperitoneal LND beyond regional may support 38780-59 with documentation
Bowel resectionAppropriate bowel CPTIf bowel resection required for oncologic or adherence reasons
Splenectomy38100-51If spleen adherent and removed separately
Diaphragm repair39502If diaphragm entered and repaired
Chest tube placement32551If thoracic access required thoracostomy drainage
Postoperative unrelated E/MAppropriate E/M with modifier -24Unrelated conditions during global period billed with -24
Return to OR for complication50220-78Unplanned return for complication within global period

50220 vs. 50225 — When to Upcode

When the surgeon must navigate significantly altered anatomy, dense adhesions, or scarring from previous surgery on the same kidney, the correct code is 50225 (complicated nephrectomy), not 50220.

Conditions supporting 50225:

  • Prior partial nephrectomy on same kidney.
  • Prior pyeloplasty or renal stone surgery with dense perirenal adhesions.
  • Prior renal trauma repair.
  • Prior nephropexy.
  • Prior retroperitoneal surgery involving same kidney with obliterated tissue planes.

Documentation requirement for 50225:

The operative note must specifically describe the nature and extent of the complication (adhesions, altered anatomy, prior incision findings) that elevated the complexity beyond a standard simple nephrectomy.

50220 vs. 50230 — Critical Selection Logic

This is the most common coding error in open nephrectomy:

Feature5022050230
Regional lymphadenectomyNoYes — required for 50230
IVC thrombectomyNoYes — included when performed
Adrenal gland removalNot requiredNot required but commonly performed
Gerota’s fascia intact vs. includedNot specifiedTypically included in radical dissection
Typical indicationBenign disease, donor, non-oncologic, small renal massRenal cell carcinoma, transitional cell carcinoma, advanced renal malignancy
wRVU~18.21~23.81

Important

The critical trigger for 50230 is lymphadenectomy or IVC thrombectomy — if the surgeon performs hilar, para-aortic, or paracaval lymph node dissection during the nephrectomy, the correct code is 50230, not 50220 with a separately reported lymphadenectomy.

wRVU

YearwRVU
202517.89
202618.21

Verify against the CMS MPFS Final Rule published November 2025 for CY2026 final values. Budget neutrality adjustments may affect published values between proposed and final rules.

Global Surgical Period

  • Global period: 090 (90-day global package)
  • All of the following are included in the surgical fee:
    • Pre-operative visit one day before surgery.
    • All intraoperative services on the day of surgery.
    • All routine post-operative follow-up visits within 90 days.
    • Drain and suture removal.
    • Management of routine post-operative complications not requiring return to OR.

Outside the global package (separately billable):

  • Unrelated medical conditions — use modifier -24.
  • Return to OR for complications — use modifier -78.
  • Staged planned procedures — use modifier -58.
  • New, unrelated surgical procedure by same surgeon — use modifier -79.

Assistant at Surgery

  • Medicare MPFS indicator: NOT payable for CPT 50220 under standard Medicare rules for simple nephrectomy.
  • Complex circumstances supporting assistant documentation:
    • Morbid obesity significantly complicating the procedure.
    • Hostile abdomen from prior retroperitoneal surgery or radiation.
    • Intraoperative hemorrhage requiring vascular control.
    • Concurrent procedures requiring a second surgeon (co-surgeon — modifier -62).
  • Commercial payers may allow assistant billing where Medicare does not — verify payer contract and policy.
  • When unusual complexity justifies increased resources, consider modifier -22 with detailed operative note documentation rather than billing an assistant that Medicare will deny.

HCC / Risk Adjustment

CPT codes do not carry HCC mapping. HCC weight is generated by the ICD-10-CM diagnosis paired with 50220:

ICD-10-CMDescriptionHCC
C64.1Malignant neoplasm of right kidneyHCC 10
C64.2Malignant neoplasm of left kidneyHCC 10
C65.1Malignant neoplasm of right renal pelvisHCC 10
C65.2Malignant neoplasm of left renal pelvisHCC 10
N28.0Ischemia and infarction of kidneyNo HCC
N13.5Crossing vessel and stricture of ureterNo HCC
Q61.xPolycystic kidney diseaseNo HCC
N10Acute pyelonephritis (xanthogranulomatous)No HCC

MS-DRG Considerations

CPT 50220 as the primary operative procedure groups under MDC 11 — Diseases and Disorders of the Kidney and Urinary Tract:

For neoplastic indications (C64.x, C65.x, D30.x, D41.x as principal):

DRGDescriptionWhen
656Kidney and Ureter Procedures for Neoplasm with MCCNeoplasm principal + MCC documented
657Kidney and Ureter Procedures for Neoplasm with CCNeoplasm principal + CC documented
658Kidney and Ureter Procedures for Neoplasm without CC/MCCNeoplasm principal, no CC/MCC

For non-neoplastic indications (infection, calculus, benign, donor):

DRGDescriptionWhen
673Other Kidney and Urinary Tract Procedures with MCCNon-neoplasm principal + MCC
674Other Kidney and Urinary Tract Procedures with CCNon-neoplasm principal + CC
675Other Kidney and Urinary Tract Procedures without CC/MCCNon-neoplasm principal, no CC/MCC

CDI note:

Documentation of comorbidities (CKD stage, hypertension, diabetes, CHF, anemia) as CC or MCC captures significantly higher DRG reimbursement. DRG 656 pays considerably more than DRG 658 — complete comorbidity capture is essential.

Common ICD-10-CM Diagnoses Paired with CPT 50220

Oncologic Indications

ICD-10-CMDescription
C64.1Malignant neoplasm of right kidney, except renal pelvis
C64.2Malignant neoplasm of left kidney, except renal pelvis
C65.1Malignant neoplasm of right renal pelvis
C65.2Malignant neoplasm of left renal pelvis
D30.01Benign neoplasm of right kidney
D30.02Benign neoplasm of left kidney
D41.01Neoplasm of uncertain behavior, right kidney
D41.02Neoplasm of uncertain behavior, left kidney

Infectious and Inflammatory Indications

ICD-10-CMDescription
N10Acute pyelonephritis (xanthogranulomatous nephritis refractory to treatment)
N13.6Pyonephrosis
N28.86Hydronephrosis with renal and ureteral calculus obstruction
N28.0Ischemia and infarction of kidney (renovascular hypertension — non-functioning kidney)

Structural and Congenital Indications

ICD-10-CMDescription
Q61.11Cystic dilatation of collecting ducts (polycystic kidney — autosomal recessive)
Q61.2Polycystic kidney, adult type (ADPKD)
Q61.4Renal dysplasia
Q61.5Medullary cystic kidney
N13.5Crossing vessel and stricture of ureter (chronic obstruction with non-functioning kidney)

Donor Nephrectomy (Note — Use Specific Donor Codes)

When performing nephrectomy for kidney donation, use the donor-specific CPT codes, not 50220:

  • 50300 — Donor nephrectomy, open, from cadaver donor.
  • 50320 — Donor nephrectomy, open, from living donor.
  • 50547 — Laparoscopic donor nephrectomy, living donor.

Adrenalectomy and CPT 50220 — Nuance

Ipsilateral adrenal gland removal during simple nephrectomy:

  • Unlike radical nephrectomy (50230), simple nephrectomy (50220) does not routinely include adrenalectomy.
  • If the ipsilateral adrenal gland is incidentally or deliberately removed as part of the simple nephrectomy dissection, the coding guidance is nuanced:
    • If the adrenal removal is incidental and minimal — bundled into 50220.
    • If the adrenal removal is a distinct, separately documented surgical step with clinical justification (adrenal mass, adrenal involvement by tumor) — consider separately reporting 60540 with modifier -59 or -XU and supporting operative note documentation.
    • Document the adrenal gland’s status, why it was removed, and the surgical steps involved separately in the operative report.

Coding Examples

Example 1 — Open Simple Nephrectomy, Right Kidney, Renal Cell Carcinoma, No Lymphadenectomy

Scenario 71-year-old with a 4.2 cm right renal mass, biopsy-proven clear cell renal cell carcinoma. Surgeon elected open nephrectomy due to patient comorbidities precluding laparoscopic approach. No lymphadenectomy performed. Adrenal gland preserved. Right flank incision, retroperitoneal approach.

CPT

  • 50220 — Nephrectomy, including partial ureterectomy, open.

ICD-10-CM

  • C64.1 — Malignant neoplasm of right kidney, except renal pelvis.

MS-DRG

  • DRG 656/657/658 depending on documented comorbidity severity.

Coding note: No lymphadenectomy performed — correct to use 50220, not 50230. If lymph nodes had been sampled or dissected, 50230 would be required.

Example 2 — Open Nephrectomy, Xanthogranulomatous Pyelonephritis, Non-Functioning Kidney

Scenario 58-year-old with left-sided xanthogranulomatous pyelonephritis and a non-functioning left kidney on nuclear medicine scan. Multiple prior left kidney procedures including percutaneous nephrostomy and prior open pyelolithotomy. Dense adhesions encountered intraoperatively — significantly prolonged dissection.

CPT

  • 50225 — Nephrectomy, open, complicated by previous surgery on same kidney (upcode from 50220 due to documented prior surgery on same kidney and dense adhesions; operative note must describe the complexity).

ICD-10-CM

  • N10 — Acute pyelonephritis (xanthogranulomatous).
  • N28.9 — Disorder of kidney, unspecified (non-functioning kidney as additional context).

Coding note: Prior surgery on the same kidney documented in operative note — supports 50225 over 50220. If prior surgery had not complicated the field, 50220 would apply.

Example 3 — Simple Nephrectomy Initially Planned, Converted to Radical

Scenario 64-year-old scheduled for open simple nephrectomy for a right renal mass. Intraoperatively, the surgeon identifies enlarged hilar lymph nodes and performs regional para-aortic lymphadenectomy. The scope of the procedure changes intraoperatively.

CPT

  • 50230 — Radical nephrectomy, open, with regional lymphadenectomy (upcode from 50220 to 50230 because regional lymphadenectomy was performed; do not bill 50220 + separate lymphadenectomy).

ICD-10-CM

  • C64.1 — Malignant neoplasm of right kidney.

Coding note: The intraoperative decision to perform lymphadenectomy changes the code from 50220 to 50230. This is the most common upgrade scenario — the operative note must document that regional LND was performed.

Example 4 — Bilateral Simple Nephrectomy, ADPKD Pre-Transplant

Scenario 45-year-old with end-stage renal disease from adult polycystic kidney disease (ADPKD). Bilateral kidneys massively enlarged, causing pain and abdominal compartment issues. Bilateral open simple nephrectomies performed as preparation for upcoming renal transplant.

CPT

  • 50220-RT — Right simple nephrectomy.
  • 50220-LT-51 — Left simple nephrectomy (modifier -51 for multiple procedures; modifier -LT for left side).
  • Alternatively, 50220-50 if payer accepts bilateral modifier for same-day bilateral nephrectomy.

ICD-10-CM

  • Q61.2 — Polycystic kidney, adult type.
  • N18.6 — End-stage renal disease.

Coding note: Bilateral nephrectomy is uncommon — document both sides explicitly in the operative note. Some payers require separate line items with -RT/-LT rather than -50; verify payer billing rules.

Example 5 — Follow-Up Visit, Subsequent Encounter in Global Period

Scenario Same patient from Example 1 returns 3 weeks post-op for routine wound check and staple removal. Incision healing well. No complications.

Coding note: This visit is included in the 90-day global surgical package for CPT 50220. Do NOT separately bill an E/M code for routine surgical follow-up within the global period. No claim is submitted for this visit from the surgeon.

Example 6 — Unrelated Condition Visit During Global Period

Scenario Same patient, 5 weeks post-op, presents with acute chest pain unrelated to the nephrectomy. Workup reveals atrial fibrillation, new onset.

CPT

  • 99215-24 — Established patient E/M, high complexity; modifier -24 indicates the visit is for an unrelated condition during the active global period.

ICD-10-CM

  • I48.91 — Unspecified atrial fibrillation (unrelated to nephrectomy — justifies the -24 modifier).

Example 7 — Return to OR for Post-Op Hemorrhage Within Global Period

Scenario Same patient, 8 days post-op, develops expanding retroperitoneal hematoma requiring emergent return to OR for evacuation and hemorrhage control.

CPT

  • 50220-78 — Return to OR for treatment of complication (post-operative hemorrhage) arising from 50220; modifier -78 indicates unplanned return to OR within the global period of the original procedure.

ICD-10-CM

  • T81.11XA — Postprocedural hemorrhage of a genitourinary system organ, initial encounter.

Key Coding Pearls

  • 50220 = open, no LND, no IVC thrombectomy — the moment lymph node dissection is documented in the operative note, the code upgrades to 50230; do not split-bill 50220 + separate lymphadenectomy.
  • Inpatient only — 50220 cannot be performed on an outpatient or ASC basis for Medicare; always inpatient hospital.
  • Partial ureterectomy is bundled — do not separately bill for the proximal ureteral segment removed with the kidney.
  • Rib resection is bundled — the descriptor explicitly states “including rib resection”; never separately bill a rib resection performed for exposure.
  • Prior surgery = 50225 — if the operative note documents significant adhesions and altered anatomy from previous surgery on the same kidney, upcode to 50225 with supporting documentation.
  • Total ureterectomy changes the code — if the entire ureter including bladder cuff is removed, use 50234 (transperitoneal, same incision) or 50236 (two separate incisions); 50220 describes partial ureterectomy only.
  • 90-day global is strict — routine follow-up visits are not billable; use -24 for unrelated conditions, -78 for return to OR, -58 for planned staged procedures.
  • Assistant not payable under Medicare for 50220 in standard circumstances; document unusual complexity if assistant assistance is clinically necessary and consider modifier -22 for significantly increased procedural services.
  • HCC lives in the diagnosis — always code the specific renal malignancy (C64.1/C64.2) to capture HCC 10 for MA patients; document all comorbidities for CC/MCC DRG capture on inpatient claims.
  • Modifier -22 documentation — if the procedure consumed substantially more time, effort, or resources than typical (hostile abdomen, hemorrhage, complex adhesions not from prior kidney surgery), modifier -22 with a detailed operative note is an option; expect payer medical review.

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