Percutaneous Nephrostomy Tube Placement

CPT 50432
Approach Percutaneous
Add-on / Variant CPTs
  • 50433 — Nephrostomy with conversion to nephroureteral stent
  • 50434 — Conversion of nephrostomy catheter to nephroureteral catheter (antegrade)
  • 50435 — Exchange of nephrostomy catheter
Preoperative Diagnosis:

Obstructive uropathy / urosepsis / urinary obstruction

Postoperative Diagnosis:

Same

Procedure Performed:

Percutaneous nephrostomy tube placement, [right / left] kidney

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

Monitored anesthesia care / general
Patient positioned prone [or prone oblique] with ipsilateral flank elevated.

Indications:

Patient presents with [obstructive uropathy from ureteral calculus / malignant ureteral obstruction / urosepsis with ipsilateral hydronephrosis / failed ureteral stent placement]. [Right / left] hydronephrosis on imaging. Urgent decompression indicated. Risks including bleeding, infection, injury to adjacent structures, and tube dislodgement discussed.

Findings:

[Moderate / severe] hydronephrosis on preprocedure imaging. Renal pelvis identified on ultrasound/ fluoroscopy. Access achieved via [posterior calyx / lower pole calyx] approach.

Description of Procedure:

The patient was positioned prone on the fluoroscopy table with ipsilateral flank elevated. The skin was prepped and draped in sterile fashion. Ultrasound was used to identify the collecting system and select a safe puncture target — the [posterior lower pole / posterior interpolar] calyx.
Under real-time ultrasound guidance, an [18-gauge] access needle was advanced through the [posterior lower pole] calyx into the renal pelvis. Urine return confirmed. A [0.035-inch] guidewire was advanced into the renal pelvis and coiled under fluoroscopic guidance. The tract was dilated with sequential dilators up to [8 French / 10 French].
A [8.5-French / 10-French] locking pigtail nephrostomy catheter was advanced over the guidewire, positioned in the renal pelvis, and the locking mechanism deployed. Position confirmed fluoroscopically with contrast injection demonstrating drainage of contrast through the catheter. The catheter was secured to the skin with a locking disk and 2-0 nylon suture, and connected to a drainage bag.
[The urine was initially [cloudy / bloody / clear].] Patient tolerated the procedure well.

Complications:

None

Specimens:

Urine sent for culture and sensitivity

Estimated Blood Loss:

Minimal

Drains:

[8.5-Fr / 10-Fr] locking pigtail nephrostomy catheter to external drainage

Disposition:

Patient taken to recovery in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: [Obstructive uropathy / urosepsis] with [right / left] hydronephrosis
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Percutaneous nephrostomy tube placement, [right / left] kidney
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: Monitored anesthesia care / general

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [obstructive uropathy from ureteral calculus / malignant ureteral obstruction / urosepsis] and [right / left] hydronephrosis on imaging. [Failed ureteral stent placement.] Urgent decompression indicated. Risks including bleeding, infection, injury to adjacent structures, and tube dislodgement were discussed. Informed consent obtained.

FINDINGS: [Moderate / severe] hydronephrosis on preprocedure imaging. Renal pelvis identified on ultrasound. Access achieved via posterior lower pole calyx. Urine [clear / cloudy / purulent].

DESCRIPTION OF PROCEDURE:
Patient positioned prone with ipsilateral flank elevated on the fluoroscopy table. Skin prepped in sterile fashion. Ultrasound used to identify the collecting system and select the posterior lower pole calyx as access target. Under real-time ultrasound guidance, an 18-gauge access needle advanced into the renal pelvis — urine return confirmed. A 0.035-inch guidewire advanced into the renal pelvis and coiled under fluoroscopy. Tract dilated sequentially to [8 / 10] French. An [8.5 / 10]-French locking pigtail nephrostomy catheter advanced over guidewire, positioned in the renal pelvis, and locking mechanism deployed. Position confirmed fluoroscopically with contrast injection demonstrating catheter drainage without extravasation. Catheter secured to skin with locking disk and 2-0 nylon suture and connected to drainage bag. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Urine for culture and sensitivity
COMPLICATIONS: None
DRAINS: [8.5 / 10]-Fr locking pigtail nephrostomy catheter to external drainage
DISPOSITION: Patient taken to recovery in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

CT-guided access

For complex anatomy, horseshoe kidney, or difficult ultrasound windows. Document CT guidance, needle angulation, and calyx selected.

Conversion to nephroureteral stent

If able to pass wire antegrade past obstruction, convert to nephroureteral stent (CPT 50433). Document guidewire passage into bladder and stent position.

Tube exchange

CPT 50435. Document existing tube removal, guidewire access, and new tube placement.

Charting Tips
  • Document imaging guidance modality (ultrasound ± fluoroscopy)
  • State calyx accessed (posterior, lower pole preferred to minimize vascular injury)
  • Document wire and tube size, locking mechanism confirmation
  • Note urine characteristics at time of drainage (purulent = urosepsis)
  • Contrast injection to confirm position and exclude extravasation
Billing Tips
  • 50432 (percutaneous nephrostomy catheter placement, 3.90 wRVU) is for primary nephrostomy tube placement under imaging guidance; 50433 (nephroureteral catheter, 4.92 wRVU) when the catheter crosses into the ureter/bladder.
  • Imaging guidance (fluoroscopy, ultrasound) is bundled into 50432/50433. Do not separately bill 76942 or 77002 for the guidance used during placement.
  • Nephrostomy tube exchange: 50435 (1.77 wRVU) is lower-weighted because it uses an existing track. Document whether a new access was required (if so, bill 50432).
  • Global period is 0 days (endoscopic). Post-placement monitoring, tube adjustments, and subsequent exchanges within the episode are each separately billable.
  • Antegrade urogram/nephrostogram (74425) performed at the same session is bundled. Bill imaging separately only when performed as a standalone diagnostic study at a separate session.
  • Document: laterality, indication (obstruction, urosepsis, stone), access site (upper/lower pole), catheter size and type, and whether contrast was used. These details are required for medical necessity.
  • If the procedure is performed in IR by a radiologist while a urologist is involved for consultation only, coordinate billing to avoid duplicate claims for the same procedure.