How To Use CPT Code 50236

CPT 50236 describes the surgical procedure for the removal of a kidney and total ureterectomy with excision of the bladder cuff through separate incisions. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 50236?

CPT 50236 is used to describe a surgical procedure that involves the removal of a kidney, total ureterectomy, and excision of the bladder cuff. This procedure is typically performed to treat renal cell carcinoma. It requires the patient to be under general anesthesia, and the surgeon makes an incision in the abdomen to access the kidney and bladder cuff. The kidney, ureter, and bladder cuff are then removed through separate incisions.

2. Official Description

The official description of CPT code 50236 is: ‘Nephrectomy with total ureterectomy and bladder cuff; through separate incision.’

3. Procedure

1. The patient is positioned correctly, and the surgeon administers general anesthesia.
2. An incision is made in the abdomen, and the surgeon proceeds to access the kidney and bladder cuff.
3. The surgeon identifies the ureter orifices and cuff of the bladder.
4. The kidney, ureter, and bladder cuff are dissected sharply and removed through separate incisions.
5. A tube is placed in the renal pelvis to allow urinary drainage.
6. The surgeon closes the incision site with sutures.

4. Qualifying circumstances

CPT 50236 is performed when a patient requires the removal of a kidney, total ureterectomy, and excision of the bladder cuff. This procedure is typically indicated for the treatment of renal cell carcinoma. It is important to note that this procedure is performed through separate incisions.

5. When to use CPT code 50236

CPT code 50236 should be used when a surgeon performs a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions. It is important to accurately document the procedure and ensure that the patient meets the qualifying circumstances for this code.

6. Documentation requirements

To support a claim for CPT 50236, the following documentation is required:

• Patient’s diagnosis necessitating the procedure
• Details of the surgical procedure performed, including the removal of the kidney, total ureterectomy, and excision of the bladder cuff
• Date of the procedure
• Incision sites used
• Any additional relevant information or complications encountered during the procedure
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT 50236, ensure that the procedure meets the criteria outlined in the official description. It is important to accurately document the procedure and provide the necessary supporting documentation. Additionally, be aware of any specific billing guidelines or modifiers that may apply to this code.

8. Historical information

CPT 50236 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. However, it is important to stay updated with any changes or revisions that may occur in the future.

9. Examples

1. A surgeon performs a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions to treat renal cell carcinoma in a patient.
2. A patient with a history of kidney disease undergoes a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions to remove a diseased kidney.
3. A surgeon performs a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions as part of a multi-step treatment plan for a patient with advanced renal cell carcinoma.
4. A patient with a recurrent kidney infection undergoes a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions to prevent further complications.
5. A surgeon performs a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions to remove a non-functioning kidney in a patient with chronic kidney disease.
6. A patient with a large kidney stone undergoes a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions to alleviate symptoms and prevent further complications.
7. A surgeon performs a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions to remove a cancerous kidney in a patient who is not a candidate for other treatment options.
8. A patient with a congenital kidney abnormality undergoes a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions to improve overall kidney function.
9. A surgeon performs a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions to remove a kidney affected by a rare genetic disorder.
10. A patient with a large kidney tumor undergoes a nephrectomy with total ureterectomy and bladder cuff excision through separate incisions to prevent the spread of cancer.