🔪 CPT 50650 — Ureterectomy, With Bladder Cuff (Separate Procedure)
Quick Reference
wRVU: 18.35 | Global Period: 090 | Assistant Payable: Yes, with documentation | Bilateral Indicator: 1
Rule: The wRVU of 18.35 reflects major open or minimally invasive abdominal surgery, well above the typical threshold for a 10-day global, so a 90-day global applies automatically. The code’s defining quirk is its AMA “separate procedure” designation, which under NCCI means it is not separately payable when performed with other procedures on the ipsilateral ureter unless true anatomic separation or distinct medical necessity is documented. Because the descriptor doesn’t specify laterality, b or modifier -50 billing follows standard paired-organ rules rather than a built-in bilateral concept.
📋 Clinical Description
CPT 50650 describes excision of all or a diseased portion of the ureter together with a surrounding cuff of bladder wall at the ureterovesical junction, most commonly performed for transitional cell (urothelial) carcinoma confined to the distal ureter where wide oncologic margins require taking the ureter and its bladder insertion en bloc rather than just resecting the ureter alone. The bladder defect created by removing the cuff is then closed primarily, and the remaining ureteral stump (if the kidney is preserved) is typically reimplanted or otherwise managed, though reimplantation itself is reported separately rather than being bundled into 50650. This code stands apart from its closest numerical sibling, 50660, which addresses excision of a congenitally ectopic ureter through a combined abdominal, vaginal, and/or perineal approach rather than an oncologic indication, and from 50234, which captures ureterectomy with bladder cuff performed in conjunction with a total nephrectomy through the same incision rather than as an isolated distal procedure.
The surgical approach for 50650 can be open transperitoneal, retroperitoneal, or laparoscopic/robotic-assisted, and the code itself does not distinguish by approach, meaning coders should rely on operative documentation rather than assumption when selecting laterality and assistant/co-surgeon modifiers. Because the “separate procedure” label signals that this excision is most often a component of a larger oncologic resection rather than a stand-alone service, accurate code selection depends heavily on confirming in the op note that no other reportable procedure in the same anatomic field already includes the ureterectomy as an inherent part of its own descriptor.
This procedure may be performed in the following clinical contexts:
- Distal ureteral urothelial (transitional cell) carcinoma — the most common indication, where a cuff of bladder is taken to ensure a clean oncologic margin at the ureterovesical junction.
- Locally invasive bladder cancer with ureteral orifice involvement, where the distal ureter and bladder cuff are excised as part of a broader resection.
- Severe, treatment-refractory benign distal ureteral stricture or fibrosis (e.g., from prior radiation or retroperitoneal fibrosis) that has failed endoscopic dilation or stenting.
- Iatrogenic ureteral injury during pelvic or gynecologic surgery where the damaged distal segment is unsalvageable and requires excision with reimplantation.
- Completion distal ureterectomy after a prior nephrectomy, performed when a retained ureteral stump becomes symptomatic, infected, or harbors recurrent urothelial tumor.
🔬 Anatomical & Procedural Considerations
| Variant | Mechanism | Key Notes |
|---|---|---|
| Open Transperitoneal/Retroperitoneal Excision | The surgeon accesses the distal ureter and ureterovesical junction through a midline or Gibson incision, mobilizes the ureter free of surrounding vasculature and peritoneum, and excises the diseased segment along with a circumferential cuff of bladder wall, closing the resulting bladder defect in two layers. | This is the traditional approach and remains preferred for bulky tumors, dense pelvic adhesions, or prior radiation, where tactile feedback and direct visualization reduce the risk of incomplete margins; it generally carries a longer hospital stay than minimally invasive alternatives. |
| Laparoscopic or Robotic-Assisted Excision | The same excision is accomplished through several small port incisions using laparoscopic or robotic instrumentation, with the bladder cuff often delivered and closed intracorporeally or through a small extraction incision. | This approach is increasingly common for isolated distal ureteral pathology without extensive local invasion, and documentation should clearly state “laparoscopic” or “robotic-assisted” since CPT 50650 does not have a separate code stem for minimally invasive technique the way some other urologic excisions do. |
| Combined with Nephroureterectomy (Distal Component) | When performed as the distal-segment portion of a nephroureterectomy through the same incision, the bladder cuff excision is captured by the nephrectomy-with-bladder-cuff codes (e.g., 50234) rather than reported separately as 50650. | Watch for operative notes describing a single continuous procedure removing kidney, ureter, and bladder cuff together; reporting 50650 in addition to a combination code in this scenario is a frequent unbundling error. |
Clinical Pearl
The single most important documentation element for 50650 is whether the bladder cuff excision was performed as a truly isolated procedure or as part of a larger combined resection, because the “separate procedure” status means CMS and most commercial payers will deny it as incidental if it’s bundled into a more comprehensive code’s own descriptor. Always confirm laterality explicitly in the op note, since -RT/-LT or modifier -50 selection cannot be inferred from the descriptor alone. When the kidney is also removed in the same session through the same incision, look first to the nephrectomy-with-bladder-cuff family before defaulting to 50650.
✅ Procedure Includes
- Surgical exposure and mobilization of the ureter from its surrounding retroperitoneal or pelvic attachments down to the ureterovesical junction.
- Excision of the diseased ureteral segment together with a circumferential cuff of bladder wall at its insertion point.
- Ligation and management of the periureteral vasculature encountered during mobilization and excision.
- Primary closure of the resulting bladder wall defect (cystorrhaphy), typically in two layers with absorbable suture.
- Placement of a closed urinary drainage catheter (Foley) and, when indicated, a perivesical drain at the closure site.
- Routine intraoperative handling and submission of the excised specimen for pathologic margin assessment.
- Standard layered closure of the surgical incision and immediate postoperative wound management.
❌ Excludes / Do Not Report Together
| Code | Description | Relationship |
|---|---|---|
| 50660 | Ureterectomy, for ectopic ureter (combined abdominal, vaginal and/or perineal approach) | This code is reserved for excision of a congenitally ectopic ureter via a multi-route approach, which is anatomically and etiologically distinct from the oncologic or stricture-driven distal excision described by 50650, and the two should never be reported for the same ureteral segment in the same session. |
| 50234 | Nephrectomy with total ureterectomy and bladder cuff; through same incision | When kidney removal and bladder-cuff ureterectomy are performed together through one incision, this combination code already includes the bladder cuff excision, so 50650 is not separately reportable on top of it. |
| 51570 | Cystectomy, partial; simple | If the bladder resection extends well beyond a cuff at the ureteral insertion to a true partial cystectomy of bladder tumor or wall, the more comprehensive cystectomy code should be selected instead of, or in addition to, 50650 depending on whether the ureteral excision is truly distinct. |
| 50715 | Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis | Per NCCI, ureterolysis is considered an integral, non-separately-reportable component of most ureteral procedures including 50650, since freeing the ureter from surrounding adhesions is inherent to performing the excision itself. |
Bundling Alert
CPT 50650 carries the AMA “separate procedure” designation, and CMS’s National Correct Coding Initiative explicitly states this code shall not be reported with other procedures performed on the ipsilateral ureter in the same operative session, meaning modifier -59 will not reliably unbundle it from related ipsilateral work unless the documentation supports a genuinely distinct anatomic site or session.1 Because the wRVU sits in major-surgery territory, the 90-day global period bundles all routine postoperative E/M visits, so any unrelated evaluation during that window requires modifier -24 with clear documentation that the visit addressed a different problem, and any planned or unplanned return to the OR for a related issue needs modifier -58 or -78 rather than a fresh, unmodified 50650. Audit risk concentrates around cases where 50650 is billed alongside a nephrectomy or cystectomy performed through the same incision, since payers will frequently flag this as inappropriate unbundling absent clear operative-note language separating the two components.
🌳 Code Tree — Surgery: Urinary System
CPT 50600-50980 Surgery: Urinary System — Ureter
│
├── 50600-50630 Incision (Ureter)
│ ├── 50620 Ureterolithotomy; middle one-third of ureter
│ └── 50630 Ureterolithotomy; lower one-third of ureter
│
├── 50650-50660 Excision (Ureter)
│ ├── ▶▶ 50650 ◀◀ Ureterectomy, with bladder cuff (separate procedure) ← YOU ARE HERE (Global: 090)
│ └── 50660 Ureterectomy, for ectopic ureter (combined abdominal, vaginal and/or perineal approach) (Global: 090)
│
└── 50684-50695 Introduction (Ureter)
└── 50684 Injection procedure for ureterography or ureteropyelography through ureterostomy or indwelling ureteral catheter (Global: 000)
💰 RVU & Reimbursement Profile
| Component | Value |
|---|---|
| Work RVU | 18.35 |
| Global Period | 090 days |
| Bilateral Indicator | 1 (150% adjustment applies if reported with modifier -50 or -RT/-LT for true bilateral excision) |
| Assistant Surgeon | Payable with documented medical necessity given the open/major nature of the dissection |
| Co‑Surgeon | Generally not applicable for an isolated ureterectomy, but may be payable with documentation when two surgeons of different specialties (e.g., urology and colorectal) are each performing a distinct part of a combined resection |
| Team Surgery | Not typically applicable to this code |
| PC/TC Split | 0 — physician service code, no professional/technical component split |
| Modifier -51 Exempt | No |
| Anesthesia | General anesthesia; ASA crosswalk generally falls within the extraperitoneal lower-abdominal/urinary-tract series, with exact base units varying by MAC and approach |
Bilateral Billing Rules
Because true bilateral ureterectomy with bladder cuff is clinically rare (most patients have one ureter affected at a time), bilateral indicator 1 applies in the unusual event both ureters require excision in the same session, in which case the code is reported once with modifier -50 and one unit of service rather than twice with -RT and -LT on separate lines. When only one side is treated, -RT or -LT should always be appended even without bilateral involvement, since omitting laterality is a common cause of claim rejection or downstream DRG/profee mismatch in inpatient review.
🏷️ Modifier Reference
| Modifier | Name | When to Apply |
|---|---|---|
| -RT | Right Side | Append when the excised ureter is the right ureter; required for laterality clarity since the base descriptor doesn’t specify side. |
| -LT | Left Side | Append when the excised ureter is the left ureter; same laterality requirement as -RT. |
| -50 | Bilateral | Use only when both ureters undergo bladder-cuff excision in the same operative session, reported as a single line with one unit rather than -RT and -LT on two lines. |
| -24 | Unrelated E/M | Appended to an evaluation and management code, not to 50650 itself, when the same surgeon sees the patient during the 90-day global period for a problem clearly unrelated to the ureterectomy. |
| -25 | Significant E/M | Appended to an E/M code billed the same day as a planned 50650 when a significant, separately identifiable evaluation drove the decision for surgery or addressed an unrelated concurrent issue. |
| -51 | Multiple Procedures | Apply when 50650 is reported with other significant, separately payable procedures in the same session that are not subject to the separate-procedure bundling restriction. |
| -59 | Distinct Service | Use sparingly given the “separate procedure” designation; only supportable when documentation establishes a genuinely distinct anatomic site, lesion, or session rather than incidental work in the same surgical field. |
| -22 | Increased Procedural Services | Apply when extensive scarring from prior radiation, retroperitoneal fibrosis, or unusually difficult dissection substantially increases the work beyond what’s typical, with supporting operative-note documentation quantifying the added complexity. |
| -53 | Discontinued | Use when the procedure is begun but terminated before completion due to a threat to patient well-being, with the operative note clearly documenting the point of discontinuation and the reason. |
| -58 | Staged | Apply when a planned, related procedure is performed during the 90-day global period of an initial 50650, such as a staged ureteral reimplantation or reconstruction anticipated at the time of the original surgery. |
| -78 | Return to OR | Apply when an unplanned return to the operating room occurs during the global period for a complication directly related to the original ureterectomy, such as a urine leak requiring re-exploration. |
| -79 | Unrelated Procedure | Apply when a separate, unrelated procedure is performed by the same surgeon during the global period of the original 50650, distinguishing it from a related complication addressed under modifier **-78**. |
| -62 | Co-Surgeon | Apply only when two surgeons of different specialties each perform a distinct, substantial portion of a combined procedure and each documents their respective role; rarely needed for an isolated ureterectomy alone. |
| -80 | Assistant Surgeon | Apply when a second physician actively assists throughout the excision and closure, with the assistant’s role clearly documented in the operative note to support medical necessity. |
🩺 Common ICD‑10‑CM Pairings
Primary Diagnosis Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| C66.1 | Malignant neoplasm of right ureter | Yes | The most frequent driver of 50650 when the right ureter is affected by urothelial carcinoma; supports both medical necessity and HCC risk capture. |
| C66.2 | Malignant neoplasm of left ureter | Yes | Mirrors C66.1 for left-sided distal ureteral urothelial carcinoma; laterality here should match the RT/LT modifier on the CPT line. |
| C66.9 | Malignant neoplasm of unspecified ureter | Yes | Reserved for documentation that doesn’t specify laterality; query the provider when possible since unspecified codes weaken both clinical accuracy and risk adjustment. |
| D41.2 | Neoplasm of uncertain behavior of ureter | No | Used when pathology has not yet confirmed malignancy, such as an indeterminate lesion pending final biopsy results at the time of resection. |
| D09.19 | Carcinoma in situ of other genitourinary organ | Yes | Appropriate when the excised tissue shows carcinoma in situ of the ureter without invasive disease, distinguishing a more limited-stage diagnosis from invasive C66.x codes. |
Secondary Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| Z85.51 | Personal history of malignant neoplasm of bladder | Yes | Relevant surveillance history when a prior bladder cancer raises suspicion for a metachronous distal ureteral tumor prompting this excision. |
| Z90.6 | Acquired absence of other genitourinary organs | No | Reported postoperatively once the ureteral segment and bladder cuff have been removed, documenting the resulting anatomic status. |
Etiology / Complication
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| N13.30 | Unspecified hydronephrosis | No | Common downstream consequence of a distal ureteral mass or stricture and frequently the presenting finding that prompts imaging leading to the diagnosis. |
| N13.4 | Hydroureter | No | Documents proximal ureteral dilation from the obstructing lesion and supports severity-of-illness capture in the inpatient record. |
Coding Specificity Reminder
Laterality is the single most consequential specificity element here, since C66.1, C66.2, and the modifier on the CPT line must all align or the claim risks denial for inconsistency. When pathology is pending at the time of discharge, query the provider rather than defaulting to an unspecified or “history of” code, since the distinction between active malignancy, neoplasm of uncertain behavior, and carcinoma in situ materially affects both DRG assignment and HCC risk capture. Avoid defaulting to a bare hydronephrosis or hydroureter code as the principal diagnosis when a more specific underlying etiology (malignancy, stricture, fibrosis) is documented and known.
🏥 MS‑DRG Considerations
Because CPT 50650 is a procedure code rather than a diagnosis code, it has no direct DRG of its own; instead, the corresponding ICD-10-PCS code drives grouping logic in combination with the principal diagnosis. Within MDC 11 (Diseases and Disorders of the Kidney and Urinary Tract), a documented ureterectomy with bladder cuff most often groups to the kidney and urinary tract procedure triad, landing in MS-DRG 656-658 (Kidney and Urinary Tract Procedures for Neoplasm) when the principal diagnosis is a malignant ureteral neoplasm such as C66.1 or C66.2. When the same excision is performed for a non-oncologic indication, such as a benign stricture or iatrogenic injury, the case instead groups to MS-DRG 659-661 (Kidney and Urinary Tract Procedures for Non-Malignancy). CC/MCC capture matters significantly for the weight assigned within either triad, so secondary diagnoses such as acute kidney injury, sepsis, or significant hydronephrosis should be coded whenever clinically supported and documented. Coders should confirm the PCS root operation selected (Resection versus Excision) matches whether the entire ureter or only a segment was removed, since this distinction can affect procedure combination logic during MS-DRG assignment.
🔧 ICD‑10‑PCS Equivalents
| PCS Code | Full Description | Modality |
|---|---|---|
| 0TT60ZZ | Resection of Right Ureter, Open Approach | Open |
| 0TT70ZZ | Resection of Left Ureter, Open Approach | Open |
| 0TT64ZZ | Resection of Right Ureter, Percutaneous Endoscopic Approach | Laparoscopic/Robotic |
| 0TBB0ZZ | Excision of Bladder, Open Approach | Open |
PCS Character Analysis (based on 0TT60ZZ, the open right-ureter resection component)
| Position | Character | Value | Definition |
|---|---|---|---|
| 1 | Section | 0 | Medical and Surgical section, covering procedures performed via incision, puncture, or external means on or in body parts. |
| 2 | Body System | T | Urinary System, the body system grouping that includes the kidneys, ureters, bladder, and urethra. |
| 3 | Root Operation | T | Resection — cutting out or off, without replacement, all of a body part, used here when the entire ureter is removed. |
| 4 | Body Part | 6 | Ureter, Right — the specific anatomic structure being resected in this example. |
| 5 | Approach | 0 | Open — entry by cutting through skin or mucous membrane and any other body layers necessary to expose the site of the procedure. |
| 6 | Device | Z | No Device — no implant, graft, or other device is left in place as part of this resection. |
| 7 | Qualifier | Z | No Qualifier — no additional qualifying detail applies to this particular resection. |
Root Operation Comparison
A complete ureterectomy maps to root operation Resection (all of the body part removed), while a partial ureterectomy that leaves a portion of the ureter in place maps instead to root operation Excision, so coders should confirm from the operative note whether “total” or “partial” language applies before selecting between the two.
Because CPT 50650 explicitly bundles the bladder cuff with the ureteral excision, facility coders typically need two PCS codes for the same encounter — one Resection or Excision code for the ureter itself, and a separate Excision code for the bladder (0TBB0ZZ) — since PCS captures each distinct body part separately even when CPT bundles them into one professional-fee code.
📝 Coding Examples
Example 1
Clinical Scenario:
A 68-year-old man presents with gross hematuria and is found on CT urogram to have a 2 cm filling defect in the right distal ureter, confirmed on ureteroscopic biopsy to be high-grade urothelial carcinoma without evidence of nodal or distant spread. He is admitted for an open right distal ureterectomy with bladder cuff excision and ureteral reimplantation. The surgeon documents mobilization of the distal right ureter, excision of the tumor-bearing segment along with a generous cuff of surrounding bladder wall, two-layer cystorrhaphy, and reimplantation of the proximal ureteral stump using a psoas hitch technique. Frozen section margins are confirmed negative intraoperatively. The patient tolerates the procedure well and is admitted postoperatively for routine recovery and drain management.
| Field | Code | Rationale |
|---|---|---|
| CPT | 50650-RT | The right-sided distal ureteral excision with bladder cuff is the primary reportable procedure, with -RT required since the descriptor itself carries no laterality. |
| PDx | C66.1 | Confirmed high-grade urothelial carcinoma of the right ureter is the documented principal diagnosis driving the admission and procedure. |
Note
The ureteral reimplantation performed in the same session is reported separately rather than being absorbed into 50650, since reimplantation is not part of this code’s descriptor; confirm the reimplant code selected matches the technique documented (e.g., psoas hitch versus simple reimplantation).
Example 2
Clinical Scenario:
A 74-year-old woman with a history of upper-tract urothelial carcinoma undergoes a planned laparoscopic left nephrectomy for a renal pelvis tumor. Intraoperatively, dense adhesions from prior pelvic radiation prevent safe laparoscopic completion of the distal ureterectomy, so the surgeon converts to an open lower-abdominal incision specifically to complete excision of the distal ureter and bladder cuff while the kidney portion remains laparoscopic. The operative note clearly documents two distinct phases of the procedure: laparoscopic nephrectomy of the kidney, and a separately approached, open excision of the distal ureteral segment with bladder cuff through a new incision. Pathology confirms high-grade urothelial carcinoma involving both the renal pelvis and distal ureter. The patient is admitted for standard post-surgical inpatient recovery.
| Field | Code | Rationale |
|---|---|---|
| CPT 1 | 50546 | Laparoscopic nephrectomy captures the kidney-removal portion performed through the original minimally invasive approach. |
| CPT 2 | 50650-LT-22 | The distal ureterectomy with bladder cuff is reported separately because operative documentation establishes it as a distinct open-approach procedure through a separate incision rather than part of a single combined nephroureterectomy code; modifier 22 reflects the documented added complexity from radiation-related adhesions. |
| PDx | C66.2 | Left ureteral urothelial carcinoma is the principal diagnosis supported by pathology and driving medical necessity for both procedures. |
Warning
This scenario only supports separate reporting of 50650 because the documentation explicitly describes a distinct approach and incision for the ureteral component rather than a single continuous nephroureterectomy; without that clear separation, payers will typically deny 50650 as bundled into the nephrectomy and the combination code 50548 (laparoscopic nephrectomy with ureterectomy) should be used instead.
Example 3
Clinical Scenario:
A 59-year-old man is six weeks status post open right ureterectomy with bladder cuff for urothelial carcinoma when he presents to the emergency department with fever, flank pain, and a CT scan showing a urine leak at the prior cystorrhaphy site with associated abscess. He is taken back to the operating room by the same surgeon for exploration, drainage of the abscess, and revision repair of the bladder closure. The patient remains within the original 90-day global period from the index ureterectomy. The return-to-OR procedure is performed solely to address this postoperative complication rather than any new, unrelated pathology.
| Field | Code | Rationale |
|---|---|---|
| CPT | 50650 not re-reported; appropriate repair code-78 | The unplanned return to the OR for a complication directly related to the original ureterectomy is reported with the applicable repair/exploration code and modifier -78, not by re-billing 50650 itself. |
| PDx | N99.84 not used here; principal Dx reflects the complication (e.g., urinary fistula or postoperative infection code per documentation) | The principal diagnosis for this encounter should reflect the specific documented complication (urine leak, abscess, surgical site infection) rather than the original neoplasm, since this is now a complication-driven admission. |
Global period reminder
Because this return to the OR falls within the 90-day global period of the index 50650 and addresses a complication of that same procedure, modifier -78 is required on the repair code to indicate a related, unplanned return rather than billing it as an unrelated new procedure. No additional payment is made for the original ureterectomy itself in this encounter, and E/M services tied directly to managing this complication remain bundled into the global period rather than separately billable.
⚠️ Common Coding Pitfalls
- Pitfall 1: Reporting 50650 in addition to a nephrectomy-with-bladder-cuff combination code (such as 50234) when both were performed through the same incision in the same session, resulting in inappropriate unbundling that payers will flag under NCCI edits.
- Pitfall 2: Confusing 50650 with 50660, since the two share a numeric neighborhood but describe entirely different clinical scenarios — oncologic or stricture-driven excision versus excision of a congenitally ectopic ureter.
- Pitfall 3: Omitting the -RT or -LT modifier because the base CPT descriptor doesn’t mention laterality, leading to claim rejection or ambiguity in the medical record about which side was treated.
- Pitfall 4: Defaulting to modifier -59 to force separate payment alongside another ipsilateral ureteral or bladder procedure without documentation supporting genuine anatomic distinctness, which runs directly counter to the code’s “separate procedure” NCCI status.
- Pitfall 5: Under-capturing CC/MCC-supporting secondary diagnoses such as hydronephrosis, acute kidney injury, or postoperative infection, which understates severity of illness and can misweight the inpatient DRG.
- Pitfall 6: Failing to document or query for the specific underlying pathology (invasive carcinoma versus carcinoma in situ versus neoplasm of uncertain behavior) before defaulting to an unspecified malignancy code, weakening both clinical accuracy and HCC risk adjustment.
📎 Sources
1. Centers for Medicare & Medicaid Services. Medicare National Correct Coding Initiative Policy Manual, Chapter 7 — Urinary System. 2026. | 2. AAPC Codify. CPT® Code 50650 — Excision Procedures on the Ureter. 2026. | 3. AAPC Codify. CPT® Code 50660 and Code Range 50650-50660. 2026. | 4. Find-A-Code. CPT 50650 RVU and Fee Information. 2026. | 5. AAPC Codify. CPT® Code 50684 — Other Introduction (Injection/Change/Removal) Procedures. 2026.