How To Use CPT Code 50610

CPT 50610 describes the procedure of ureterolithotomy, specifically targeting the upper one-third of the ureter. This article will provide an overview of CPT code 50610, including its official description, the step-by-step procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 50610?

CPT 50610 is a code used to describe the surgical procedure known as ureterolithotomy. It involves making an incision into the upper one-third of the ureter to remove a stone that is causing obstruction or other complications. This procedure is performed by a healthcare provider who is experienced in urological surgeries.

2. Official Description

The official description of CPT code 50610 is: ‘Ureterolithotomy; upper one-third of ureter.’ This code specifically refers to the surgical removal of a stone from the upper portion of the ureter.

3. Procedure

1. The healthcare provider begins by preparing the patient for the procedure, ensuring they are appropriately prepped and anesthetized.
2. An incision is made in the skin of the abdomen overlying the upper one-third of the ureter.
3. The provider then carefully dissects the surrounding muscles, fat, and fascia to expose the ureter.
4. Once the ureter is visible, the provider makes an incision in the ureteral wall directly over the stone.
5. The stone is then removed through the incision in the ureter.
6. A catheter is inserted to flush the surgical site with a sterile saline solution, ensuring there are no remaining stones or fragments.
7. The provider repairs the incision in the ureter and takes measures to stop any bleeding.
8. Finally, the layers of tissue in the abdominal incision are sutured together to close the wound.

4. Qualifying circumstances

CPT code 50610 is used when a stone is located in the upper one-third of the ureter and requires surgical removal. The procedure is typically performed on patients who are experiencing symptoms or complications due to the presence of the stone. It is important that the healthcare provider performing the procedure has the necessary expertise in urological surgeries.

5. When to use CPT code 50610

CPT code 50610 should be used when a healthcare provider performs a ureterolithotomy procedure specifically targeting the upper one-third of the ureter. It is important to accurately document the location of the stone and the specific procedure performed to ensure proper coding and billing.

6. Documentation requirements

When reporting CPT code 50610, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the ureterolithotomy procedure
• Specific details of the procedure, including the location of the stone and the incision made in the ureter
• Date of the procedure and the duration of the surgery
• Any complications or additional procedures performed during the surgery
• Post-operative care instructions and any follow-up appointments scheduled
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 50610, it is important to ensure that the procedure was performed on the upper one-third of the ureter. This code should not be reported if the stone is located in the middle or lower one-third of the ureter, as separate codes exist for those specific scenarios (50620 and 50630, respectively). It is also important to follow any specific billing guidelines provided by insurance companies or payers to ensure accurate reimbursement.

8. Historical information

CPT code 50610 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone no updates or changes since its addition.

9. Examples

1. A urologist performing a ureterolithotomy to remove a stone from the upper one-third of the ureter in a patient with recurrent urinary tract infections.
2. A surgeon conducting a ureterolithotomy procedure to address a stone causing severe pain and obstruction in the upper portion of the ureter.
3. A healthcare provider performing a ureterolithotomy on a patient with hydronephrosis due to a stone in the upper one-third of the ureter.
4. An interventional radiologist performing a ureterolithotomy to remove a stone causing renal colic in the upper portion of the ureter.
5. A urological surgeon conducting a ureterolithotomy procedure to address a stone causing hematuria and urinary retention in the upper one-third of the ureter.
6. A healthcare provider performing a ureterolithotomy on a patient with a large stone causing recurrent kidney infections in the upper portion of the ureter.
7. A urologist conducting a ureterolithotomy procedure to remove a stone causing renal impairment and pain in the upper one-third of the ureter.
8. A surgeon performing a ureterolithotomy to address a stone causing urinary incontinence and flank pain in the upper portion of the ureter.
9. A healthcare provider conducting a ureterolithotomy on a patient with a stone causing ureteral stricture and recurrent kidney stones in the upper one-third of the ureter.
10. A urological surgeon performing a ureterolithotomy procedure to remove a stone causing urinary frequency and urgency in the upper one-third of the ureter.