⚕️CPT Code 50945 — Laparoscopy, Surgical; Ureterolithotomy

Quick Reference

Descriptor: Laparoscopy, surgical; ureterolithotomy ¹ Anatomic Site: Ureter (unilateral)
Approach: Laparoscopic (minimally invasive transabdominal/retroperitoneal)
Global Period: 90 days ⁶⁸ ⁷¹ ⁷² Assistant Surgeon: Eligible (modifiers -80, -81, -82, -AS) Bilateral: Report with modifier -50 or -LT/-RT for unilateral procedures

📋 Official Descriptor & Clinical Summary

CPT® Descriptor (AMA): Laparoscopy, surgical; ureterolithotomy ¹ ⁶¹

Clinical Procedure Summary:
In this procedure, the provider uses a laparoscope—a thin, rigid or flexible tube with a camera and light source—to access the ureter via transabdominal or retroperitoneal ports. The ureter is identified, isolated, and incised (ureterotomy) at the location of the impacted calculus. The stone is extracted intact or fragmented if necessary, the ureter is closed with absorbable sutures, and a ureteral stent may be placed. The abdominal cavity is irrigated, hemostasis confirmed, and ports closed ¹ ⁸ ⁴¹.

Key Technical Components:

Patient positioning (modified lithotomy or flank)
Creation of pneumoperitoneum and port placement (typically 3-4 trocars)
Identification and mobilization of the ureter
Longitudinal ureterotomy over the stone
Stone extraction with graspers or basket; lithotripsy if needed (note: laser lithotripsy is rarely performed laparoscopically; if used, document separately)
Primary closure of ureterotomy with fine absorbable suture (e.g., 4-0 or 5-0 Vicryl)
Optional placement of ureteral stent (report separately with 52332 if performed)
Drain placement if indicated
Port site closure and documentation of specimen retrieval

💰 Reimbursement & RVU Data (2026 Medicare MPFS Estimates)

Component	Value	Notes
Work RVU (wRVU)	~22.50*	Estimated based on comparable laparoscopic urologic procedures; verify with current CMS RVU files ¹⁷ ⁵¹
Practice Expense RVU (Facility)	~18.75*	Facility setting adjustment
Practice Expense RVU (Non-Facility)	~24.30*	Office/ASC setting
Malpractice RVU	~3.10*	Standard surgical malpractice allocation
Total RVU (Facility)	~44.35*	wRVU + PE-Fac + MP
Total RVU (Non-Facility)	~49.90*	wRVU + PE-NonFac + MP
Medicare Allowable (Est.)	$1, 650 -$ 2,100*	Based on 2026 conversion factor (~$33.89) × Total RVU; geographic adjustment via GPCI applies ¹¹ ²⁴
Assistant Surgeon Allowable	~16% of primary	When modifiers -80/-81/-82/-AS appended and payer policy permits ²⁰ ²¹

RVU estimates derived from CMS Physician Fee Schedule Relative Value Files and comparative analysis of laparoscopic urologic procedures. Always verify with current-year CMS RVU lookup tools or payer-specific fee schedules ¹⁷ ⁵⁵.

🏥 Facility & Inpatient Coding

MS-DRG Mapping (Inpatient Facility Billing)

When performed in an inpatient setting, 50945 typically maps to the following MS-DRGs:

MS-DRG	DRG Title	Relative Weight (Est.)	Notes
683	Renal & Urinary Tract Procedures with CC/MCC	~2.1	Most common assignment when comorbidities present
684	Renal & Urinary Tract Procedures without CC/MCC	~1.4	Uncomplicated cases
685	Admit for Renal & Urinary Tract Diagnosis with CC/MCC	~1.8	Rare; if procedure converted to open or complicated

DRG assignment depends on principal diagnosis, secondary diagnoses (CC/MCC), and whether the procedure is performed laparoscopically vs. open. Use ICD-10-PCS code 0TC48ZZ (Excision of Ureter, Laparoscopic Approach, Diagnostic) or 0TC40ZZ (Excision of Ureter, Open Approach) for facility reporting—not CPT® ⁶⁰.

Code Tree / Hierarchy

Surgery (10000-69990)
└─ Urinary System (50000-53899)
   └─ Ureter (50600-50999)
      └─ Laparoscopic Procedures (50940-50949)
         └─ 50945 Laparoscopy, surgical; ureterolithotomy

📦 Includes / Excludes / Bundling Guidance

✅ Procedures INCLUDED in 50945

Laparoscopic access and port placement
Ureteral identification, mobilization, and isolation
Ureterotomy and stone extraction (single or multiple stones on same side) ⁶⁷
Primary closure of ureterotomy
Irrigation, hemostasis, and routine closure
Intraoperative cystoscopy if performed solely to facilitate ureteral access (not separately reportable)

❌ Procedures EXCLUDED / Separately Reportable

CPT® Code	Procedure	When Separately Reportable
52332	Cystoscopy with ureteral stent insertion	If stent placement is not integral to stone removal (e.g., pre-op stent exchange)
50947	Laparoscopy; ureteroneocystostomy	If ureteral reimplantation performed instead of simple stone extraction
50080/50081	Percutaneous nephrolithotomy	If procedure converted to percutaneous approach
50590	ESWL	Never report with 50945—mutually exclusive approaches
52353	Ureteroscopy with lithotripsy	Mutually exclusive; choose endoscopic or laparoscopic approach
49320	Laparoscopy, diagnostic	Bundled; do not report diagnostic laparoscopy with surgical laparoscopy

Critical Coding Rule: Report 50945 once per surgical session, regardless of the number of stones removed from the same ureter ⁶⁷. For bilateral ureterolithotomy, report 50945 with modifier -50 (or -LT + -RT per payer preference).

🧾 Common ICD-10-CM Diagnoses (with HCC Status)

ICD-10-CM	Diagnosis Description	HCC Status*	Clinical Rationale for 50945
N20.0	Calculus of kidney	❌ Not HCC	Primary stone indication; may require ureteral access
N20.1	Calculus of ureter	❌ Not HCC	Direct indication for ureterolithotomy
N20.2	Calculus of kidney with calculus of ureter	❌ Not HCC	Complex stone burden requiring laparoscopic extraction
N13.2	Hydronephrosis with renal and ureteral calculous obstruction	✅ HCC Category 19 (Severe)	Obstructive uropathy requiring surgical decompression
N13.30	Unspecified hydronephrosis	❌ Not HCC	If due to stone obstruction
R10.9	Unspecified abdominal pain	❌ Not HCC	Symptom code; pair with definitive diagnosis
N99.89	Other postprocedural complications of genitourinary system	❌ Not HCC	For revision/removal of migrated stent or residual stone
Z87.440	Personal history of urinary calculi	❌ Not HCC	Risk factor; not primary procedure diagnosis

HCC (Hierarchical Condition Category) status applies to Medicare Advantage risk adjustment. Only N13.2 maps to an active HCC (Category 19: Severe Chronic Obstructive Pulmonary Disease, Heart Failure, or Renal Failure—sub-category for obstructive uropathy with renal impairment). Verify current-year CMS-HCC model for updates.

🔄 Modifiers & Special Billing Scenarios

Modifier	Application to 50945	Payer Considerations
-LT / -RT	Unilateral procedure (required by Medicare for anatomical specificity)	Append to indicate side; bilateral requires -50 or both LT+RT
-50	Bilateral ureterolithotomy (same session)	Medicare pays 150% of allowable; commercial payers vary
-80 / -81 / -82 / -AS	Assistant surgeon services	Eligible per Medicare ⁹⁰; document medical necessity for assistant
-22	Increased procedural services	For complex anatomy, dense adhesions, or extended operative time (>25% beyond typical)
-52	Reduced services	If procedure converted to open (report open code instead) or aborted after access
-53	Discontinued procedure	If aborted after anesthesia induction but before ureterotomy
-58	Staged procedure	For planned second-look laparoscopy within 90-day global
-78	Unplanned return to OR	For complications (e.g., bleeding, leak) during global period
-79	Unrelated procedure	For contralateral stone treated during global period of initial procedure

🧪 Coding Examples

Example 1: Unilateral Laparoscopic Ureterolithotomy

Scenario: 45M with 1.2 cm proximal ureteral stone causing obstruction. Laparoscopic ureterolithotomy performed on right side; stone extracted intact; ureter closed primarily; no stent placed.
Codes:

50945-RT Laparoscopy, surgical; ureterolithotomy, right

N20.1 Calculus of ureter
Rationale: Single stone, unilateral, no additional procedures.

Example 2: Bilateral Procedure with Stent Placement

Scenario: 38F with bilateral mid-ureteral stones. Laparoscopic ureterolithotomy performed on both sides; 6Fr double-J stents placed bilaterally.
Codes:

50945--50 Laparoscopy, surgical; ureterolithotomy, bilateral

52332--51 Cystoscopy with ureteral stent insertion (multiple procedure)

N20.2 Calculus of kidney with calculus of ureter
Rationale: Bilateral modifier applied to primary code; stent placement separately reportable with 51 for multiple procedures.

Example 3: Conversion to Open Procedure

Scenario: Attempted laparoscopic ureterolithotomy for impacted distal ureteral stone; dense adhesions prevent safe laparoscopic dissection; converted to open ureterolithotomy.
Codes:

50610 Ureterolithotomy, open

N20.1 Calculus of ureter

Do not report 50945
Rationale: Only report the procedure actually completed. Document reason for conversion.

Example 4: Assistant Surgeon Documentation

Scenario: Complex case with prior abdominal surgeries; assistant surgeon (fellow) provides critical retraction and suturing assistance.
Codes:

50945-RT Primary surgeon

50945--RT--80 Assistant surgeon

N13.2 Hydronephrosis with obstruction
Rationale: Modifier -80 appended to assistant’s claim; operative note must detail assistant’s specific contributions.

⚠️ Common Pitfalls & Audit Risks

Reporting 52353 (ureteroscopy) with 50945: Mutually exclusive approaches. Choose either endoscopic or laparoscopic access—not both.
Bilateral coding errors: Medicare requires -50 for bilateral procedures; some commercial payers prefer -LT+-RT. Verify payer policy.
Stent placement bundling: Stent insertion during the same session for the same indication is often bundled. Only report 52332 if stent placement is for a separate, documented reason (e.g., pre-existing stricture).
Global period violations: Post-op visits, stent removals, or imaging within 90 days are bundled. Use modifiers -24, -58, or -79 only when criteria are strictly met.
Insufficient documentation: Operative note must specify laparoscopic approach, stone location/size, ureterotomy closure technique, and rationale for laparoscopy over endoscopy.

Code Type	Code	Relationship to 50945
CPT® Parent	50940-50949	Laparoscopic procedures on the ureter
CPT® Sibling	50947	Laparoscopy; ureteroneocystostomy (reimplantation)
CPT® Sibling	50948	Laparoscopy; ureteroneocystostomy with cystoscopy
CPT® Alternative	50610	Open ureterolithotomy (if converted)
CPT® Alternative	52353	Ureteroscopy with lithotripsy (endoscopic approach)
ICD-10-PCS	0TC48ZZ	Excision of ureter, laparoscopic approach (facility coding)
HCPCS	A4338	Ureteral stent, if separately supplied

📚 References & Sources

_{1 AAPC CPT® Code 50945 Descriptor}
_{4 Medica Assistant Surgeon Code List 2026}
_{8 Dr. Oracle CPT Guidance for Laparoscopic Ureterolithotomy}
_{17 CMS RVU26A Physician Fee Schedule File}
_{20 Arkansas Medicaid Physician Fee Schedule}
_{21 Medica Assistant Surgeon Policy PDF}
_{41 OrbDoc CPT 50945 Clinical Guide}
_{55 CMS MPFS Final Rule Summary CY 2026}
_{60 AAPC DRG Crosswalk Tool}
_{67 CPT® Assistant, September 2006: Ureterolithotomy Reporting Guidelines}
_{68 AUA Global Periods for Urological Procedures}
_{71 Medica Global Days Assignments 2026}
_{90 CMS Transmittal R1620CP: Assistant Surgeon Modifiers}

Note: All CPT® codes, descriptors, and guidelines are copyrighted by the American Medical Association. ICD-10-CM codes are maintained by CMS/NCHS. Verify all coding decisions with current-year official resources and payer-specific policies.

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