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2025 CPT code 50230

Radical nephrectomy, including removal of the kidney, a portion of the ureter, the adrenal gland, and the surrounding fatty tissue.

Follow all applicable CPT coding guidelines, including those related to surgical procedures, and ensure accurate documentation to support the level of service rendered.

Modifiers may be applicable based on the specific circumstances of the procedure (e.g., 50 for bilateral procedures, 51 for multiple procedures, 59 for distinct procedural services). Consult the CPT manual for detailed modifier guidelines.

Radical nephrectomy is medically necessary for the treatment of renal cell carcinoma and other malignant renal tumors that are surgically resectable. It is also indicated in certain cases of benign renal disease that may be at risk for malignant transformation.

The clinical responsibility rests with a surgeon specializing in urology or general surgery. The surgeon performs the nephrectomy, ensuring complete removal of the affected kidney and adjacent structures.They are also responsible for pre-operative assessment, post-operative care, and managing any complications that might arise.In complex cases, an assistant surgeon may be involved.

IMPORTANT:Use CPT code 50225 if the same surgery has been performed on the same kidney in the past. Use CPT code 50234 if nephrectomy was performed with total removal of ureter and bladder cuff through the same incision. Use CPT code 50236 if nephrectomy was performed with total removal of ureter and bladder cuff through separate incisions. Use CPT code 50240 if the physician only removed the diseased or infected portion of the kidney. Use CPT codes 50300–50320 for the donor. Use CPT code 50340 for recipient nephrectomy. For excision of retroperitoneal tumor or cyst, see 49203-49205. For laparoscopic ablation of renal mass lesion(s), use 50542.

In simple words: This surgery removes a kidney, part of a tube that carries urine (ureter), the adrenal gland (on top of the kidney), and nearby fatty tissue.It's a major operation that may involve removing lymph nodes and blood clots.

Radical nephrectomy involves the complete surgical removal of a kidney, encompassing the kidney itself, a segment of the ureter, the adrenal gland located superior to the kidney, and the perirenal fat (fatty tissue surrounding the kidney).The procedure typically requires a significant incision, potentially involving rib resection for optimal surgical access.Regional lymphadenectomy (removal of lymph nodes) and/or vena caval thrombectomy (removal of blood clots from the vena cava) may also be performed depending on the extent of the disease.

Example 1: A 65-year-old male patient presents with a large renal cell carcinoma (kidney cancer) involving the upper pole of the right kidney.The tumor has invaded the perirenal fat and adjacent tissues. Radical nephrectomy of the right kidney is performed to remove the cancerous tissue and prevent recurrence., A 50-year-old female patient with a history of von Hippel-Lindau (VHL) syndrome is found to have a large, complex renal cyst and several smaller cysts in the left kidney. Because of the patient's history and the complexity of the disease, a radical nephrectomy of the left kidney is performed to address all cancerous tissues. This is a preventative radical nephrectomy to reduce the risk of developing kidney cancer., A 40-year-old male patient presents with a large renal tumor extending into the inferior vena cava.A radical nephrectomy with vena cava thrombectomy is performed. The surgeon carefully removes the tumor, including the thrombus from the vena cava, ensuring complete resection of the cancerous tissue and preventing further spread.

* Detailed history and physical examination documenting the indication for radical nephrectomy.* Pre-operative imaging studies such as CT scan or MRI demonstrating the extent of the tumor and involvement of surrounding structures.* Intra-operative findings including size and location of the tumor, extent of resection, and any complications encountered.* Pathology report confirming the diagnosis and extent of the disease.* Post-operative course, including any complications or adverse events.

** This code encompasses various surgical approaches, including open and laparoscopic techniques.The specific surgical approach used should be reflected in the operative report.

  • Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
  • Payment Status: Active
  • Modifier TC rule: Not applicable.
  • Specialties:Urology, General Surgery
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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