What CPT (Current Procedural Terminology) code is reported for the surgical repair of a small 2 cm kidney laceration?

CPT Code Selection for Kidney Laceration Repair

The correct CPT code for repair of a small 2 cm kidney laceration is 50500.

Understanding CPT Coding for Kidney Trauma Repair

When selecting the appropriate CPT code for kidney laceration repair, it's essential to consider the specific nature and extent of the procedure performed. In this case, the urologist repaired a small 2 cm laceration of the kidney following a motor vehicle accident (MVA).

Analysis of Code Options:

1. 50500: Nephrorrhaphy, suture of kidney wound or injury

   • This code specifically describes the surgical repair (suturing) of a kidney wound or injury
   • Most appropriate for simple kidney lacerations requiring suture repair

2. 50520: Closure of nephrocutaneous or pyelocutaneous fistula

   • This code is for repair of abnormal connections between the kidney and skin
   • Not applicable to traumatic kidney lacerations without fistula formation

3. 50525: Closure of nephrovisceral fistula (e.g., renocolic), including visceral repair

   • This code involves repair of fistulas between kidney and other organs
   • Includes additional visceral repair
   • Not applicable to simple kidney lacerations

4. 50526: Closure of nephrovisceral fistula (e.g., renocolic), with visceral transplantation

   • This code involves more complex procedures with organ transplantation
   • Not applicable to simple kidney laceration repair

Clinical Decision Making

The key factors in this case are:

• The injury is described as a "small 2 cm laceration"
• The procedure involved examination and repair of the kidney laceration
• No mention of fistula closure or involvement of other organs
• No mention of complex reconstruction or transplantation

Coding Pitfalls to Avoid

1. Overcoding: Selecting codes 50525 or 50526 would represent overcoding as these describe more complex procedures than what was performed.

2. Undercoding: Using evaluation codes without capturing the surgical repair would result in undercoding.

3. Mismatched codes: Selecting fistula repair codes (50520,50525,50526) for a simple traumatic laceration would be incorrect.

Conclusion

Based on the clinical scenario described, the urologist performed a nephrorrhaphy (surgical repair of a kidney wound) on a small 2 cm laceration. Therefore, CPT code 50500 is the correct code to report this service.