How To Use CPT Code 50540

CPT 50540 describes a surgical procedure known as symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 50540?

CPT 50540 is a code used to describe a surgical procedure called symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral. This procedure involves the incision of anomalous tissue connecting two kidneys, allowing them to become two separate structures. The provider may also perform a reconstruction procedure, such as pyeloplasty of the kidney’s renal pelvis.

2. Official Description

The official description of CPT code 50540 is: ‘Symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral (1 operation).’ This code is used when the provider performs a symphysiotomy to separate the isthmus, the band of renal or fibrous tissue connecting the two kidneys, and may also perform additional plastic procedures if necessary.

3. Procedure

1. When performing CPT 50540, the provider begins by making an incision, typically across the abdomen, to access the kidneys.
2. Next, the provider separates the isthmus, the band of renal or fibrous tissue connecting the two kidneys, from the surrounding muscles, fat, and other tissue.
3. The provider then incises the isthmus and sutures the incision site on each side to create two separate kidney structures.
4. If needed, the provider may also perform pyeloplasty on the renal pelvis or other plastic repair procedures on one or both sides.
5. After completing the necessary procedures, the provider cleanses the operative site with sterile saline solution and controls any bleeding.
6. A separate drain tube may be placed through a separate incision in the skin, if required.
7. Finally, the provider removes all surgical instruments and closes the incision in layers.

4. Qualifying circumstances

CPT 50540 is performed on patients with a horseshoe kidney, which is a congenital partial fusion defect of the right and left kidneys resulting in one large horseshoe-shaped kidney structure. The procedure may also involve pyeloplasty, which is the surgical repair of the kidney’s renal pelvis. This code is used when the provider performs symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral.

5. When to use CPT code 50540

CPT code 50540 should be used when the provider performs symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral. It is important to accurately document the specific procedures performed and the medical necessity for each procedure.

6. Documentation requirements

To support a claim for CPT 50540, the provider must document the following information:

• Diagnosis of horseshoe kidney and the need for symphysiotomy
• Details of any additional procedures performed, such as pyeloplasty or other plastic repairs
• Date of the procedure
• Operative technique used
• Any complications or unexpected findings
• Post-operative care instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 50540, ensure that the procedure performed meets the criteria for symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral. It is important to accurately code and document any additional procedures performed. CPT code 50540 should not be reported with other codes unless they are distinct and separate procedures performed during the same operative session.

8. Historical information

CPT code 50540 was added to the Current Procedural Terminology system on January 1, 1990. The code description was revised on January 1, 2010, to clarify the inclusion of unilateral or bilateral procedures. It is important to stay updated with any changes or revisions to the code.

9. Examples

1. A provider performs symphysiotomy for horseshoe kidney with pyeloplasty on the left side during a single operative session.
2. A patient with a horseshoe kidney undergoes symphysiotomy without any additional plastic procedures.
3. A provider performs symphysiotomy for horseshoe kidney with bilateral pyeloplasty and drainage during a single operative session.
4. A patient with a horseshoe kidney requires symphysiotomy and exploration with biopsy on the right side.
5. A provider performs symphysiotomy for horseshoe kidney with pyeloplasty, exploration, biopsy, and drainage on the left side during a single operative session.
6. A patient with a horseshoe kidney undergoes symphysiotomy for unilateral pyeloplasty and drainage as separate procedures.
7. A provider performs symphysiotomy for horseshoe kidney with exploration and drainage on the right side.
8. A patient with a horseshoe kidney requires symphysiotomy and exploration with biopsy and drainage on the left side.