CPT 51590 - Cystotomy, with removal of ureteral calculus and/or foreign body; with ureteral reimplantation

Procedure Description

51590 describes an open surgical procedure involving the urinary bladder (cystotomy) performed to remove a calculus (stone) or foreign body located in the ureter, followed by the reimplantation of the ureter into the bladder.

This is a major surgical procedure typically performed under general or regional anesthesia. The surgeon makes an incision in the lower abdomen to access the bladder. The bladder is incised (cystotomy) to expose the ureteral orifice. The distal ureter is mobilized, and any obstructing calculus or foreign body is removed. The ureter is then reimplanted into the bladder wall (ureteroneocystostomy), often involving the creation of a new tunnel through the bladder muscle to prevent vesicoureteral reflux. A stent may be placed, and the bladder and abdominal incisions are closed in layers.

Key Components

Approach: Open (abdominal incision).
Site: Bladder and distal ureter.
Action: Incision of bladder, removal of stone/foreign body, reimplantation of ureter.
Global Period: 90 Days (Major Surgery).

CPT Code Tree / Hierarchy

This code falls under the Surgery section of the CPT manual, specifically within the Urinary System subsection.

Surgery
- Urinary System
  - Kidney
    - Introduction
      - Cystotomy
        
        51500 Cystotomy, with removal of calculus, foreign body, or clot
        
        51501 Cystotomy, with removal of ureteral calculus, foreign body, or clot; with repair of ureter
        
        51505 Cystotomy, with evacuation and/or destruction of abnormal intravesical lesion (eg, tumor), with or without biopsy
        
        …
        
        51590 Cystotomy, with removal of ureteral calculus and/or foreign body; with ureteral reimplantation
        
        51595 Cystotomy, with removal of ureteral calculus, foreign body, or clot; with ureteral reimplantation and psoas hitch procedure

Valuation and Payment Data

Metric	Value	Notes
Work RVU (wRVU)	16.93	Based on Medicare Physician Fee Schedule (Non-Facility). Values subject to annual update and geographic adjustment.
Total RVU	Varies	Depends on Facility vs. Non-Facility setting and Geographic Practice Cost Indices (GPCI).
Assistant Payable	Yes (1)	Surgical assistant services are typically reimbursable for this code.
Bilateral Indicator	0	0 = Bilateral surgery does not apply (Unilateral procedure).
Endoscopy Indicator	0	Not an endoscopic procedure.
Status Indicator	A	Active code.

ICD-10-CM Coding Information

When reporting 51590, the diagnosis codes must support medical necessity. The primary diagnosis should reflect the condition necessitating the stone removal and reimplantation (e.g., calculus, stricture, obstruction).

Common Associated Diagnoses

ICD-10 Code	Description	HCC Status
N20.1	Calculus of ureter	No
N20.2	Calculus of kidney with calculus of ureter	No
N13.2	Hydronephrosis with renal and ureteral calculous obstruction	No
N13.4	Hydroureter	No
N13.5	Kinking and stricture of ureter without hydronephrosis	No
N13.6	Pyonephrosis	No
T19.0	Foreign body in urethra and urinary bladder	No
N18.31	Chronic kidney disease, stage 3a	Yes (HCC 138)
N18.32	Chronic kidney disease, stage 3b	Yes (HCC 138)
N18.4	Chronic kidney disease, stage 4	Yes (HCC 138)
N18.6	End stage renal disease	Yes (HCC 134)

HCC (Hierarchical Condition Category) Notes

HCC Status applies to risk adjustment modeling (e.g., Medicare Advantage).
Urologic stone disease codes (N20.x, N13.x) are generally not HCC codes.
If the patient has concurrent Chronic Kidney Disease (CKD), codes from category N18 should be reported if documented, as these are HCC codes and impact risk adjustment scores.
Always code to the highest level of specificity documented in the medical record.

Includes and Excludes

Includes

Open incision into the bladder.
Removal of ureteral calculus or foreign body.
Ureteroneocystostomy (reimplantation of ureter into bladder).
Creation of new ureteral tunnel within bladder wall.
Closure of bladder and abdominal layers.

Excludes / Do Not Report Separately

51500: Cystotomy with removal of calculus (included in 51590).
51501: Cystotomy with removal of ureteral calculus with repair of ureter (51590 is more specific when reimplantation is performed).
50945: Ureteroscopy (Do not report if open cystotomy is performed for the same lesion).
52351: Cystourethroscopy with removal of ureteral calculus (Do not report open and endoscopic removal for the same stone).
Routine closure of bladder and abdomen.
Placement of ureteral stent (often included in the reimplantation procedure unless distinct circumstances apply; check payer policy).

Modifier Usage

50: Bilateral Procedure (Not applicable, code is unilateral).
51: Multiple Procedures (If other distinct procedures are performed).
59: Distinct Procedural Service (If performed with other procedures that are usually bundled).
80: Assistant Surgeon (If an assistant is utilized and payable).
22: Increased Procedural Services (If work required is substantially greater than typically required).

MS-DRG (Inpatient Setting)

While 51590 is predominantly performed in an outpatient or Ambulatory Surgical Center (ASC) setting, if the patient is admitted as an inpatient due to complications or comorbidities, the following MS-DRGs may apply based on the principal procedure and presence of Complications or Comorbidities (CC/MCC).

MS-DRG	Description	Relative Weight (Approx)
689	Kidney and Urinary Tract Procedures with CC/MCC	Higher
690	Kidney and Urinary Tract Procedures without CC/MCC	Lower

Note: DRG assignment depends on the principal diagnosis and the presence of secondary diagnoses that qualify as CC or MCC.

Coding Examples

Example 1: Distal Ureteral Stone with Obstruction

Scenario: Patient presents with severe flank pain and hematuria. CT scan reveals a 1.5 cm impacted stone in the distal left ureter causing hydronephrosis. Endoscopic attempts failed previously. Patient undergoes open cystotomy, stone removal, and ureteral reimplantation.

CPT: 51590 (Left side, consider modifier LT if required by payer)
ICD-10: N20.1 (Calculus of ureter), N13.2 (Hydronephrosis with renal and ureteral calculous obstruction)
Rationale: The procedure matches the definition of cystotomy with stone removal and reimplantation.

Example 2: Foreign Body Removal and Reimplantation

Scenario: Patient has a migrated stent fragment lodged in the distal ureter causing erosion. Surgeon performs open cystotomy, removes the foreign body, and reimplants the ureter due to tissue damage at the original orifice.

CPT: 51590
ICD-10: T19.0 (Foreign body in urethra and urinary bladder - verify specific code for ureter foreign body if available, otherwise use injury code), N13.5 (Kinking and stricture of ureter)
Rationale: Code 51590 covers removal of foreign body with reimplantation.

Example 3: Concurrent CKD

Scenario: Same as Example 1, but patient has documented Stage 4 Chronic Kidney Disease.

CPT: 51590
ICD-10: N20.1, N13.2, N18.4
HCC Impact: N18.4 is an HCC code and will affect risk adjustment scoring, unlike the stone codes.

Clinical Documentation Requirements

To support 51590, the operative report must clearly document:

Approach: Confirmation that the procedure was open (not laparoscopic or endoscopic).
Cystotomy: Explicit mention of the incision into the bladder.
Pathology: Identification of the calculus or foreign body.
Reimplantation: Description of the ureteroneocystostomy (tunneling, suturing of ureter to bladder mucosa).
Laterality: Left, Right, or Bilateral (if rare bilateral open procedure performed, requires modifier).
Closure: Method of closing the bladder and abdominal wall.

Potential Auditing Risks

Unbundling: Reporting 51500 or 51501 along with 51590 is incorrect as the components are inclusive.
Endoscopic vs. Open: If the procedure was started open but converted to endoscopic, or vice versa, code the final method performed. Do not report both unless distinct separate lesions were addressed via different approaches.
Stent Placement: Routine stent placement during reimplantation is generally included. Separate reporting of stent insertion codes may be denied unless specific payer policies allow it for distinct management.
Laparoscopic Conversion: If the procedure was attempted laparoscopically but converted to open, report the open code 51590. Some payers may require modifier 50 (not applicable here) or specific conversion modifiers; check local guidelines. Usually, no specific modifier is required for conversion unless specified by payer, but documentation must support the conversion reason.

50945 Ureteroscopy
52351 Cystourethroscopy, with removal of ureteral calculus
50947 Ureteral catheterization or stent insertion, separate procedure
51595 Cystotomy, with removal of ureteral calculus, foreign body, or clot; with ureteral reimplantation and psoas hitch procedure (Use if psoas hitch is also performed)
50941 Laparoscopy, surgical; ureteral reimplantation

Explorer

51590