Key takeaways from this episode

• 50688 is the only code in the group specific to an ileal conduit. It covers a change of a ureterostomy tube or externally accessible ureteral stent via ileal conduit, and it does not require radiologic supervision and interpretation.
• 50385 and 50387 both require radiologic supervision and interpretation. If you are not using fluoroscopy or other radiologic guidance to remove and replace the stent, neither code applies; the same requirement runs through the whole 503 family, including snare removal with 50382.
• The difference between 50385 and 50387 is internally dwelling versus externally accessible. 50385 is a transurethral removal and replacement of an internally dwelling ureteral stent; 50387 is an externally accessible nephroureteral catheter, typically a patient with a nephrostomy in place, though CPT does not mandate the nephrostomy approach.
• Read the CPT section sequence and the parenthetical notes for the whole family. Both codes sit under kidney, introduction, renal pelvis catheter procedures, and the note under 50387 directs removal without replacement of an externally accessible stent that does not need fluoroscopy to the evaluation and management codes; that note applies to 50382 through 50386 as well.
• Per ICD-10, BCG induction is coded to C67.X and maintenance to Z85.51. Active bladder cancer codes apply during the induction and treatment phase; once the patient moves to maintenance with no visible cancer, the personal-history code is the correct diagnosis.
• Drop C67.9 from your list and code the site of the bladder cancer. Many payers are rejecting the unspecified code as not specific enough, so documentation needs to state where the tumor was.
• When a payer repeatedly denies BCG on the Z85 code, appeal first, then switch to payer-navigation coding. Check the denial reason (a missed prior auth is fixed differently than medical necessity), appeal with your notes the first time, and for a repeat offender list C67.X first and carry Z85.51 on the claim without attaching it to the 51720 or BCG line; Blue Cross Blue Shield of Arizona was the payer in this question.
• Do not forget prior authorization on high-dollar maintenance therapies. Denials for missing prior auth on expensive bladder cancer treatments tie up significant money, and secondary payers have caused problems as well.

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 287, recorded May 2026, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network.

Stent removal and replacement codes 50385, 50387 and 50688

[00:00] Scott Painter: On this episode, stent removal and replacement codes. Also, ICD-10 codes for bladder cancer maintenance. Stay tuned. Welcome to episode 287 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host, Mark Painter, and Dr. Ray Painter. We had a couple of questions come in from our PRS Network members, and one of them came from our friend Karanterant. She asked for an explanation of some stent removal and replacement codes. In particular, she was asking about codes 50385, 50387 and 50688. Mark, what's going on with these codes? Can you explain a little of the why behind the question, as much as you can piece together, and see if you can get her the answers she's looking for?

[01:17] Mark Painter: All right. Let's actually start with the highest code, 50688, and I mean highest in CPT number. This is a code for a change of a ureterostomy tube or externally accessible ureteral stent via ileal conduit. It is the one code in the list she gave us that is specific to the ileal conduit, and that's really the differentiation. It is important to read to the end. A lot of times with short descriptions, we don't see everything that's part of the CPT code. It is a change of a ureterostomy tube or an externally accessible ureteral stent, but it is via the ileal conduit. That is definitely a different approach and a different anatomy for the patient, and that drives us to the 506 code and why it's not starting with 503 like the other codes we're talking about today. So that one is really driven by the anatomy of the patient.

Now, 50387 and 50385 are both removal and replacement codes, but 50385 is focused on the removal and replacement of an internally dwelling ureteral stent. It is transurethral in approach. And one of the important parts is that it includes, or requires, radiologic supervision and interpretation. If you are not using fluoroscopy or some type of radiologic guidance to remove and replace a stent, this is not the code for you.

We've had questions on some of the other codes in the same family, that 503 family, and specifically the straight removal via a snare or capture of an internally dwelling catheter, which is 50382. Because some people were using the shorter snares to grab the string and remove a stent, it's important that all of the codes in the 503 family use radiologic supervision and interpretation. It's a more complex procedure than simply pulling the string, or grabbing that string with a snare instead of using a scope to grab the stent and pull it out.

So we'll start with that. Once we put the commonality in that both require radiologic supervision and interpretation, and I mean 50385 and 50387, the difference is the following. And by the way, I will mention that 50688 does not require radiologic supervision and interpretation. So, trying not to get too much of the word salad going: 50688 is no radiologic supervision or interpretation required, but access through the ileal conduit. 50387 and 50385 both require radiologic supervision. The difference between those two codes is that 50385 is for an internally dwelling ureteral stent, and 50387 is the externally accessible nephroureteral catheter.

That would typically mean the patient has a nephrostomy in place, and you've got a tube or a catheter outside of the kidney. That really is the difference between those two codes. There's nothing from a CPT perspective that would state you have to approach through the nephrostomy. But judging from the typical language, and the fact that it's already externally accessible, that might be one of the considerations that went into making these two separate codes, that the approach might be different. I would assume that would be the case, but I learned long ago that assumptions shouldn't be made. There is not a directive within the CPT code that says the removal and replacement needs to be done through the nephrostomy, but it does need to be externally accessible, so it does need to be accessible via a nephrostomy. That's really the difference between the 87 and the 85. But both, remember, require radiologic supervision and interpretation in order to be used.

Using the CPT section sequence to interpret the codes

[07:04] Scott: Ray, comments, questions?

[07:08] Dr. Ray Painter: Well, the codes there can sometimes be interpreted different ways, and "externally accessible" threw me, because where is it accessible? But I went back to the coding today and looked at the sequence of codes. CPT does place codes in sequence, and that helps you sometimes really determine what the code means. If you look at the sequence on 50385 and 87, they are both under kidney, introduction, and then renal pelvic catheter procedures. That's the way the sequence of the code goes, and that tells you that it should be externally accessible through the flank area. So that's just another perk, and Scott can tell you how to do that. He taught me a long time ago.

[08:22] Scott: What Ray's referring to are the sections and subsections of CPT. You have the overall section of surgery, and then it drills down into the urinary system, into the kidney, then introduction, and then into the subsection of renal pelvis catheter procedures. For the 85, the final subsection is internally dwelling, whereas 50387 is in the subsection externally accessible. If you look in your CPT book, you can look at the table of contents and see that. Or if you're in AUA Coding Today, when you're in the code itself you can see what are called breadcrumbs, and it will show you those different sections and subsections as it drills down above the code. That's an easy way to look at what sequence, as Ray says, the code is in, what section, subsection, et cetera. Anything else to add to that, Ray?

[09:41] Ray: Nope.

[09:43] Scott: Mark, anything more on this question?

[09:46] Mark: Nope. Hopefully we were clear enough on all of that. I know we got bounced around a little bit, but hopefully everybody got the answer to the question.

[09:55] Scott: One thing I will bring up. I just remembered that as we were talking in the prep for this, we saw a parenthetical, some guidance underneath code 50387, that said: for removal without replacement of an externally accessible ureteral stent not requiring fluoroscopic guidance, see evaluation and management service codes. You had mentioned that was added because a lot of practices were using this without the fluoroscopic guidance. Is that correct? Did I have that right?

[10:33] Mark: Yes, that is correct.

[10:35] Scott: So if you're not using the fluoroscopic guidance, you'd go to the evaluation and management section.

[10:40] Mark: Yeah. Ultimately, this is one of the translation issues you run up against in the computer, in the way CPT is laid out. We don't always see those parenthetical notes that apply to the family under every code in the family. It's under 87 because that's the last code in the family, versus under each of the other codes, 50382 through 86.

ICD-10 coding for BCG induction versus maintenance

[11:14] Scott: Got it. All right, let's move on to the next question. The next question came in from Lillian, and Lillian asks: "Can you please review this guidance from a urologist and provide feedback? BCG induction therapy every week for six weeks is coded with ICD-10 codes C67.0 through C67.9 for current bladder cancer. BCG maintenance therapy every six months for three years is coded with ICD-10 code Z85.51 for personal history of bladder cancer." All right, Mark, what's the trend here? Why is this being asked, and can you explain it?

[12:10] Mark: All right. I think the way the question is answered is that the urologist may have gone to the Urology Advanced Coding and Reimbursement Seminar and learned how to correctly use diagnosis codes according to ICD-10. While you're in the treatment phase of bladder cancer, you use the bladder cancer codes, because the patient has an active cancer. The one thing I'll add is that although C67.9 is in fact an active ICD-10 code, we are seeing many payers rejecting that as not specific enough, because a patient with a diagnosis of bladder cancer should have a diagnosis that indicates where that bladder cancer was. It should not go under the unspecified code. So you want to take that list and shave C67.9 out, and really focus on making sure your documentation includes the location where the bladder cancer was originally. We would assume that when you're in the BCG stage it's been removed at that point in time, but you're in that active treatment phase until you move to maintenance. In that case the patient has, according to ICD-10, a history of bladder cancer that you are now providing maintenance therapy on, because you don't have active bladder cancer that is visible. So that is the correct ICD-10 approach.

However, I bet this question came through because we are seeing some payers who look at the Z history code, the Z85, as not requiring BCG, and we're seeing denials. I have a feeling that question came through because they're having some payment problems, as payers have filtered payment for BCG onto the C67 codes. So you've got to watch where the payers are. This isn't accurate ICD-10 coding, but unfortunately it is payer-specific coding: you may have to default to the C67.X code that the patient had originally, and then you could potentially add the Z code later to indicate that you're not in the active treatment phase. But you may need to list the C67 code as number one, even though the ICD-10 coding guidelines say we should use the Z code, and the payers should accept that Z code. As we all know, the payers are not in it for the true care of the patient. They're in it for denying claims, so they make it a little tricky.

Handling a denial on the Z85.51 history code

[15:49] Scott: Ray, comments, questions?

[15:51] Ray: No. Nothing to add.

[15:55] Scott: All right. Well, I have a question on that, just to clarify. Let's say you get a denial for the ICD-10 code Z85.51, personal history, when you're in the maintenance mode of treating bladder cancer. Are you first going to try and appeal that, or would you immediately slap on a C67.X code? How would you go about that?

[16:29] Mark: The first thing I'm going to look at is what is my reason for denial. If the denial is because I forgot to do the prior authorization, then I'm not going to change anything. I'm going to go back and appeal that based on the fact that we need to fix the prior authorization. If my denial is medical necessity, with payers the first time through I would probably run the appeal to try and educate the payer with my notes. But if I see this as a repeat problem with that particular payer, and it's really gumming up the works and I can't get it through, then is when I would make the decision to start, for that payer, using the C67 code in the first position, and then the Z code on the claim, but not necessarily assigned to the line of service, the 51720 or the BCG. So you're still providing the information; you're just navigating the payer rules in that circumstance. And I've got to tell you, that is not correct ICD-10 coding. That is correct payer navigation coding, which we have to consider.

[17:58] Scott: Yeah, especially with this kind of treatment, because most of this maintenance therapy is very expensive, and there's a lot of money out there. Any delay is certainly problematic.

[18:12] Mark: Yes, that is true. And I'll mention it: don't forget your prior auths, especially on those bigger ones. Those are going to kill you.

[18:21] Scott: Yeah. And this is where we had a discussion. We'd mentioned that the secondary insurance caused some problems with this.

[18:29] Mark: Yes.

[18:31] Scott: So there are a lot of games being played because of these high-dollar treatments.

[18:39] Mark: Well, payers are a pain in the butt in general.

[18:42] Scott: And this one, by the way, I just noticed is Blue Cross Blue Shield in Arizona. So there you go.

[18:50] Mark: So keep an eye on that, and do pay attention to what your denials are. As everyone knows, it's rarely one size fits all. So pay attention to what that denial is. And ultimately, when we get questions like this, if you give us a little background, we can give you a more directed answer. But at the same time, I appreciate the ability to pontificate about everything that's happening.

[19:22] Scott: Yeah, and others may hear this and not be experiencing it now, but it may come up in a week or two or a month or two.

[19:31] Mark: Yeah.

[19:32] Scott: It's always good to have that background education.

[19:34] Mark: Yep.

Sponsor, the seminar, and the Urology Hub

[19:36] Scott: All right. Well, let's wrap this episode up. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prsnetwork for specials for our listening audience. Also, I want to make you aware, and Mark mentioned it in the podcast, that our Urology Advanced Coding and Reimbursement Seminar is open for registration. I want to make sure you all understand what this is. We understand that AI is out there. We understand there are a lot of changes going on in the urology practice, and we are monitoring all of that and gathering all this information. So it's not a learn-how-to-code seminar. It's really about the urology practice: how do you survive, how do you thrive in this world of AI, payer scrutiny and all these changes. That's what the Urology Advanced Coding and Reimbursement Seminar is evolving into. We're evolving as the market's evolving, and one of the most crucial pieces in your urology practice today is communication and community. You can't survive and thrive if you're practicing in a silo. You've got to be in touch with what's happening in the marketplace and with other urology practices, not only within your state or your MAC geography, but across the country.

This question we just answered is a very good example. There may be a payer out there in a specific state doing something, in this case denying the cancer maintenance for bladder cancer because of the ICD-10 codes, and that's something you can be aware of. If you see that, you can make those changes more quickly so you don't have all that money you have tied up in these advanced therapies sitting out there and not being collected. That's really what the Urology Advanced Coding and Reimbursement Seminar is all about. We encourage you to come and join us. It's a great two days. There's one in December in Las Vegas and one in January 2027 in New Orleans. It's worth it. It's a great experience for all the practices that join us and develop that community that's so needed in today's environment.

The final thing I'll mention is our Urology Hub. If you go to prsnetwork.com/urologyhub, on those hub pages we're taking the various categories in urology and breaking them down from a coding and reimbursement perspective, what's going on in the marketplace now, and then tying those categories back to products. For example, last week on the podcast we talked about C9761. There's a lot of new information, and everything about C9761 is up in the air. There are a lot of questions on what scopes can be used for kidney stones, whether it's a sheath scope or a Calyxo CVAC scope; there are all sorts of different interpretations out there. On the hub, we help clarify what's going on and what you need to do in order for your urologist to use those scopes in the various outpatient settings. I know the ASCs and the HOPDs are the ones really impacted by C9761, but it's the urologists who have those tools in their hands, and what they can use and what their preference is are all part of this as well. So it's all there on the hub. We try to explain it in a way that's easy to understand. We also have our PRS CodeMatrix guides available for download for free. That's the PRS interpretation: we look at all the different devices or therapies out there and boil it down to a one-page quick reference guide. If you go to prsnetwork.com/urologyhub, you can check out all the different CodeMatrix guides and calculators. All right, that's a lot. Let's get some final thoughts on today's episode. Mark, final thoughts.

Final thoughts

[24:41] Mark: All right, I'll keep it brief because you rambled about everything, which is good. These are times, as Scott mentioned, with AI, in which we're seeing the payers tighten the screws across the board, because they're getting tightened on from the revenue stream. So it is a changing world, a changing environment, and keeping the human in the loop and informed is key. There are times when we make decisions that follow the payer rules but not necessarily the coding rules as we navigate the payment process. It's not what I would consider ideal, but unfortunately it is part of the program. So you want to make sure you've got your communication down, you've got your people in place, and you've got your network of support inside and outside of the practice well-oiled. It's going to take a village to solve all this. It's going to take AI, it's going to take supervision, and in the end it really relies on education and accuracy as a starting point, while understanding that the rules bent by the payer are things we have to comply with. But be careful. We had our discussion last week in the webinar about PCR and how to navigate that. Stick to your guns where it's appropriate, but there are times when we can navigate these crazy rules and still be accurate. That's the environment we're in today.

[26:44] Scott: Ray, final thoughts.

[26:46] Ray: The devil is in the details, and keep in mind the hierarchy of rules, as we've talked about many times. At the top of that list is payer-specific coding and billing. Very true.

[27:07] Scott: All right. That's all we have for today. Thank you all for listening. Take us out, Ray.

[27:14] Ray: Happy coding.

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