50620

⚕️CPT Code 50620 - Ureterolithotomy, Calculus Removal

Quick Reference

Descriptor: Ureterolithotomy, calculus removal; upper one-third of ureter, including cystoscopy ¹
Global Period: 90 days ⁶²
Assistant Surgeon: Payable with modifiers -80, -81, -82, -AS -52
wRVU: 13.66 | Total RVU: 23.46 (Non-Facility) ¹⁵
NCCI Status: Bundles diagnostic cystoscopy 52000; modifier indicator “1” for distinct procedures ⁷¹
Approach: Open Surgical (Incision)

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📋 Code Description & Clinical Context

50620 describes an open surgical procedure to remove a calculus (stone) from the upper one-third of the ureter ¹. This procedure involves making an incision (typically flank or abdominal) to access the ureter, opening the ureter (ureterotomy), removing the stone, and closing the ureter. The descriptor explicitly includes cystoscopy performed during the same session ⁴.

Key Clinical Indications:

• Large impacted ureteral calculi not amenable to ureteroscopy or ESWL
• Failed minimally invasive attempts (ureteroscopy, shock wave lithotripsy)
• Upper ureteral stones causing severe obstruction, infection, or renal compromise
• Anatomical anomalies preventing endoscopic access

Anatomical Specificity

This code is specific to the upper one-third of the ureter. Stones located in the middle or lower one-third require different codes (e.g., 50630 for middle, 50640 for lower) ²⁶.

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🌲 Code Hierarchy / Tree

Surgery (10000-69990)
└─ Urinary System (50000-55999)
   └─ Ureter (50500-50999)
      └─ Incision
         ├─ 50610 Ureterolithotomy, calculus removal; lower one-third of ureter
         ├─ 50620 Ureterolithotomy, calculus removal; upper one-third of ureter ← THIS CODE
         ├─ 50630 Ureterolithotomy, calculus removal; middle one-third of ureter
         └─ 50640 Ureterolithotomy, calculus removal; lower one-third of ureter (abdominal approach)

Parent Category: Incision Procedures on the Ureter ²⁶
Laparoscopic Counterpart: 50548 (Laparoscopic ureterolithotomy) - Do not report both for same stone/session ⁹³
Endoscopic Counterpart: 52356 (Cystourethroscopy with ureteroscopy and lithotripsy) ⁹³

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💰 Reimbursement & Valuation

Component	Facility	Non-Facility	Notes
Work RVU	13.66	13.66	Physician effort component 15
Practice Expense RVU	6.50	7.85	Overhead/equipment (higher in office) 15
Malpractice RVU	1.95	1.95	Liability component 15
Total RVU	22.11	23.46	Base for payment calculation
Global Period	90 days	90 days	Major surgery; includes 1 pre-op + surgery day + 90 post-op days 6268

Assistant Surgeon Payable: Yes

• Report with modifiers: -80 (Assistant Surgeon), -81 (Minimum Assistant), -82 (Assistant when resident unavailable), or -AS (PA/NP/CNS assistant) ⁵²
• Medicare Status Indicator: “1” (Payment permitted for assistant)
• Reimbursement typically 16-25% of primary surgeon fee depending on payer policy

Medicare Payment Estimate: National average ~$850-$950 (Physician Fee), Facility fees separate ⁵¹

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🚫 Includes / Excludes & NCCI Guidance

✅ Includes

• Open incision to access the upper ureter
• Ureterotomy (incision into the ureter)
• Removal of calculus (stone)
• Repair of ureteral incision
• Cystoscopy performed during the same operative session (bundled) ⁷¹
• Placement of ureteral stent (if performed, often bundled or separate depending on payer; check 50945)
• Intraoperative imaging (fluoroscopy) typically bundled unless extensive

❌ Excludes / Bundled Per NCCI

• Diagnostic cystoscopy 52000 (explicitly included in descriptor) ⁷¹
• Ureteroscopy 52351/52356 on the same ureter for the same stone (mutually exclusive approaches) ⁷⁸
• ESWL 50590 on the same stone/session
• Open procedures for middle/lower ureter stones (use 50630 or 50640)
• Laparoscopic ureterolithotomy 50548 (different approach)

NCCI Edit Critical Note

Diagnostic cystoscopy 52000 is bundled into 50620 with a modifier indicator of “0” ⁷⁴. It cannot be billed separately under any circumstances during the same session. However, if a distinct procedure (e.g., bladder tumor resection) is performed, modifier 59 may be applicable if the edit allows (Indicator “1”) ⁷¹.

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🏥 MS-DRG Assignment (Inpatient Facility)

If performed in an inpatient setting (rare for uncomplicated stones, common for complex/infected cases):

Scenario	MS-DRG	Description
Primary procedure: Kidney & Urinary Tract Procedures for Non-Malignancy with MCC	689	Highest severity/complexity 92
Primary procedure: Kidney & Urinary Tract Procedures for Non-Malignancy with CC	690	Moderate complexity 92
Primary procedure: Kidney & Urinary Tract Procedures for Non-Malignancy without CC/MCC	691	Baseline complexity 92

Note

Inpatient admission must meet severity criteria. Uncomplicated stone removal is typically outpatient/ASC ⁹¹.

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🏷️ Common ICD-10-CM Diagnosis Codes

Primary Diagnosis Options

ICD-10-CM Code	Description	HCC Status*
N20.0	Calculus of kidney	❌ Not HCC
N20.1	Calculus of ureter	❌ Not HCC
N20.2	Calculus of kidney with calculus of ureter	❌ Not HCC
N20.9	Urinary calculus, unspecified	❌ Not HCC
N13.2	Hydronephrosis with renal and ureteral calculous obstruction	❌ Not HCC
N13.4	Hydroureter	❌ Not HCC
N10	Acute tubulo-interstitial nephritis (if infection present)	❌ Not HCC

• HCC Status: Hierarchical Condition Category mapping for Medicare Advantage risk adjustment. Urinary calculus codes (N20.x, N13.x) are generally not HCCs in current CMS-HCC models ^{101 114}. They are considered acute/episodic. Chronic Kidney Disease (CKD) codes (e.g., N18.3-, N18.4) are HCCs and should be reported if documented.

Supporting/Comorbid Codes (Document When Applicable)

• N18.30 Chronic kidney disease, stage 3 unspecified (HCC applicable)
• N18.4 Chronic kidney disease, stage 4 (HCC applicable)
• N18.5 Chronic kidney disease, stage 5 (HCC applicable)
• Z87.440 Personal history of urinary (tract) calculi
• R39.15 Urinary retention (if applicable)

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✏️ Modifiers Guidance

Modifier	Use Case for 50620	Payable?
-50	Bilateral Procedure: stones removed from upper ureter on both left and right sides	✅ Append to 50620 (or report LT/RT depending on payer)
-51	Multiple Procedures: when performed with other distinct procedures (e.g., nephrolithotomy)	✅ Subject to multiple procedure reduction
-59	Distinct Procedural Service: if cystoscopy involves distinct work (e.g., bladder biopsy) not bundled	⚠️ Verify NCCI edit indicator first
-80 / -81 / -82 / -AS	Assistant Surgeon services	✅ Payable per Medicare policy 52
-22	Increased Procedural Services: stone exceptionally large, impacted, or anatomy difficult	✅ If documentation supports & NCCI allows
-53	Discontinued Procedure: terminated due to patient risk (e.g., inability to locate stone)	✅ With operative note detail
-LT / -RT	Left Side / Right Side: Specify laterality if not using -50	✅ Required for clarity

Modifier -50 Usage

The ureters are paired organs. If stones are removed from the upper third of both ureters during the same session, report 50620--50 (or 50620--LT and 50620--RT). Do not report twice without modifier -50 unless payer specifies ⁷⁷.

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📝 Coding Examples

✅ Example 1: Standalone Open Ureterolithotomy

Scenario: 55 y/o M with large impacted stone in proximal right ureter. Failed ESWL. Surgeon performs open flank incision, isolates upper ureter, performs ureterotomy, removes 1.5cm stone, places stent, closes ureter. Cystoscopy performed to place stent.
Report:

• 50620--RT (Ureterolithotomy, upper ureter)
• N20.1 (Calculus of ureter)
• N13.2 (Hydronephrosis with obstruction)
  Rationale: Procedure matches descriptor. Cystoscopy is bundled ⁹⁷.

❌ Example 2: Billing Cystoscopy Separately (Incorrect)

Scenario: Same as Example 1. Surgeon bills 50620 and 52000 (Cystoscopy).
Report: 50620 + 52000
Rationale: Incorrect. 52000 is explicitly included in the descriptor of 50620 and bundled per NCCI with modifier indicator “0” ⁷¹.

⚠️ Example 3: Bilateral Procedure

Scenario: Patient has symptomatic stones in upper third of both left and right ureters. Surgeon performs open ureterolithotomy on both sides during same anesthesia.
Report:

• 50620--50 (Bilateral procedure)
• N20.2 (Calculus of kidney with calculus of ureter) or N20.1
  Rationale: Ureters are paired. Modifier -50 indicates bilateral performance ⁷⁷.

✅ Example 4: Assistant Surgeon Participation

Scenario: Complex reoperative flank surgery. Assistant surgeon provides exposure, retraction, and suturing assistance.
Report:

• Primary: 50620--RT
• Assistant: 50620--80--RT
• Diagnosis: N20.1
  Rationale: Assistant surgeon services are payable for 50620; document assistant’s specific contributions ⁵².

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🔍 Documentation Essentials for Support

To support 50620 and mitigate audit risk, operative documentation should include:

1. Approach: Explicitly state “open” approach (flank, abdominal, or lumbar incision).
2. Location: Specify upper one-third of the ureter. (Critical for code selection vs 50630/50640).
3. Procedure: Describe ureterotomy, stone removal, and closure.
4. Cystoscopy: Mention cystoscopy was performed (do not bill separately, but document it was done as part of the procedure).
5. Stone Details: Size, number, and location of calculi removed.
6. Stent Placement: Document if internal stent was placed (often bundled, but supports medical necessity).
7. Laterality: Clearly indicate Left, Right, or Bilateral.

Anatomical Precision

Ensure the operative note distinguishes between upper, middle, and lower ureter. Coding auditors will verify stone location against the code selected. If the stone migrated or was found in the middle third, report 50630 instead.

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⚠️ Common Pitfalls & Audit Risks

Pitfall	Consequence	Prevention
Reporting 52000 with 50620	Claim denial (Bundled)	Remember cystoscopy is included in descriptor 71
Using 50620 for laparoscopic approach	Incorrect coding (Upcoding/Downcoding)	Use 50548 for laparoscopic ureterolithotomy 93
Using 50620 for middle/lower ureter stone	Incorrect coding	Use 50630 (middle) or 50640 (lower) based on anatomy 26
Omitting Modifier -50 for bilateral cases	Underpayment	Append -50 or LT/RT modifiers as per payer policy 77
Failing to document CKD status	Lost HCC Risk Adjustment	Document Chronic Kidney Disease stage if applicable (e.g., N18.30) 101

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🔗 Related Codes & Crosswalks

Code Type	Code	Relationship to 50620
CPT®	50630	Ureterolithotomy, middle one-third of ureter
CPT®	50640	Ureterolithotomy, lower one-third of ureter
CPT®	50548	Laparoscopic ureterolithotomy (different approach)
CPT®	52356	Ureteroscopy with lithotripsy (endoscopic approach)
CPT®	50590	Extracorporeal shock wave lithotripsy (non-invasive)
CPT®	50945	Ureteroscopy with stent insertion (if stent only)
ICD-10-PCS	0TCB0ZZ	Extirpation of Matter from Ureter, Open Approach (inpatient procedure coding)
HCPCS	None directly	No specific HCPCS Level II code crosswalk

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¹ AMA CPT 2024 Professional Edition
⁴ AUA Guidelines on Surgical Management of Stones
¹⁵ CMS Medicare Physician Fee Schedule 2024
²⁶ NIH VSAC CPT Hierarchy
⁵¹ PayerPrice Fee Schedule 2026
⁵² Medicare Claims Processing Manual Ch. 12
⁶² CMS Global Surgery Factsheet
⁶⁸ Noridian Medicare Local Coverage Determinations
⁷¹ CMS NCCI Policy Manual 2024
⁷⁴ AAPC NCCI Edit Resources
⁷⁷ Coding Mastery Modifier Guidelines
⁷⁸ AHA Coding Clinic for ICD-10-CM/PCS
⁹¹ CMS Two-Midnight Rule Guidance
⁹² CMS MS-DRG Manual v41.0
⁹³ AUA Ureteroscopy Guidelines
⁹⁷ AAPC Coding Ureterolithotomy Procedures
¹⁰¹ CMS-HCC Model V28 Documentation
¹¹⁴ Find-A-Code HCC Mapping Tool