Resection and Fulguration (Endoscopic Management)

• 50557 — Renal endoscopy through established nephrostomy or pyelostomy; with fulguration and/or incision, with or without biopsy
• 50562 — Renal endoscopy through established nephrostomy or pyelostomy; with resection of tumor
• 50576 — Renal endoscopy through nephrotomy or pyelotomy; with fulguration and/or incision, with or without biopsy
• 52354 — Cystourethroscopy with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion
• 52355 — Cystourethroscopy with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor

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Chemoablation with JELMYTO (Mitomycin Pyelocalyceal Instillation)

Retrograde approach using cystoscope

• 52005 — Cystourethroscopy, with ureteral catheterization
• 74420 — Urography, retrograde, with or without KUB (if performed)
• J9281 — Mitomycin pyelocalyceal instillation, 1 mg
• J9281-JW — JW modifier for wastage

Antegrade approach via established nephrostomy tube

• 50391 — Instillation of therapeutic agent into renal pelvis and/or ureter through established nephrostomy tube
• 50431 — Injection procedure for antegrade nephrostogram and/or ureterogram; existing access (if performed)
• 74420 — Urography, retrograde, with or without KUB (if performed)
• J9281 — Mitomycin pyelocalyceal instillation, 1 mg
• J9281-JW — JW modifier for wastage

• C65.1 — Malignant neoplasm of right renal pelvis
• C65.2 — Malignant neoplasm of left renal pelvis
• C66.9 — Malignant neoplasm of unspecified ureter
• C66.1 — Malignant neoplasm of right ureter
• C66.2 — Malignant neoplasm of left ureter
• C68.9 — Malignant neoplasm of urinary organ, unspecified

If billing for JELMYTO, document the amount administered and the amount discarded. This documentation has been a focus area in RAC audit activity.

• Include administered dose (mg) and discarded dose (mg) clearly in the procedure note.
• Ensure the claim line(s) support JW usage when wastage is billed.

Example #1 — Resection of Renal Pelvic Tumor

The patient was taken to the operating room and placed in the dorsal lithotomy position under general anesthesia. After appropriate sterile preparation and draping, a cystourethroscopy was performed.

The right ureteral orifice was identified, and a guidewire was advanced into the ureter under fluoroscopic guidance. A ureteroscope was then introduced over the wire and advanced up the ureter and into the renal pelvis.

A papillary tumor was visualized in the renal pelvis. Using a biopsy forceps and laser fiber, the tumor was carefully resected and ablated in a piecemeal fashion, with care taken to preserve surrounding normal tissue. All visible tumor was removed. Biopsy specimens were sent to pathology for evaluation. The collecting system was inspected post-resection and appeared hemostatic with no evidence of perforation.

How would you code this?

Answer: 52355

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Example #2 — JELMYTO Instillation in ASC

Patient is being seen in the ASC today for instillation of JELMYTO (mitomycin for pyelocalyceal solution) as part of treatment for low-grade upper tract urothelial carcinoma. A total of 39 mg was instilled into the renal pelvis via a ureteral catheter with retrograde urography. The procedure was well-tolerated with no immediate complications. Following administration, 41 mg of the JELMYTO was discarded.

How would you code this?

Answer:

Physician (professional) claim lines
52005 — Cystourethroscopy, with ureteral catheterization
74420 — Urography, retrograde, with or without KUB
J9281 — Mitomycin pyelocalyceal instillation, 1 mg (administered units: 39)
J9281-JW — JW modifier for wastage (discarded units: 41)

Site-of-service facility billing rules vary by payer. Some Commercial Payers and Medicare Advantage plans may not recognize C-codes, and some plans may not process J-codes as expected.

Facility procedure / packaged service codes (site-of-service dependent)

• C9789 — Instillation of anti-neoplastic pharmacologic/biologic agent into renal pelvis, any method, including all imaging guidance, including volumetric measurement if performed
• J9281 — Mitomycin pyelocalyceal instillation, 1 mg

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When the physician is billing professional services in a facility setting (for reference)

• 52005 — Cystourethroscopy, with ureteral catheterization
• 74420-26 — Urography, retrograde, with or without KUB (professional component)
• J9281 — Mitomycin pyelocalyceal instillation, 1 mg
• J9281-JW — JW modifier for wastage

• C65.1 — Malignant neoplasm of right renal pelvis
• C65.2 — Malignant neoplasm of left renal pelvis
• C66.9 — Malignant neoplasm of unspecified ureter
• C66.1 — Malignant neoplasm of right ureter
• C66.2 — Malignant neoplasm of left ureter
• C68.9 — Malignant neoplasm of urinary organ, unspecified

Facilities should ensure documentation supports both drug units billed and any discarded amount when JW is applicable and accepted by the payer.

• Document administered dose (mg) and discarded dose (mg) clearly in the procedure note and/or MAR.
• Confirm payer rules for C-codes vs J-codes (many commercial and MA plans vary).
• Ensure charge capture aligns with the site-of-service (ASC vs HOPD rules differ).

Site-of-service notes (ASC vs HOPD)

Coding and payment can differ by payer and by setting. Many commercial payers and Medicare Advantage plans may not recognize C-codes, and some plans may not process J-codes as expected.

Operational tip

To reduce denials, standardize how dose administered vs dose discarded is captured in the clinical workflow (procedure note + medication administration documentation + charge capture).