Clinical Context
A 68-year-old male with an incidentally discovered 2.5 cm enhancing cortical mass in the right kidney on abdominal CT is evaluated by a urologist and interventional radiologist. The mass is suspicious for small renal cell carcinoma in a patient with significant cardiopulmonary comorbidity that increases surgical risk for partial nephrectomy. After multidisciplinary discussion, the patient is scheduled for percutaneous radiofrequency ablation (RFA) of the renal mass.
The clinical workflow includes pre-procedure imaging review and informed consent, pre-procedure labs (coagulation panel, basic metabolic panel), and temporary discontinuation or management of anticoagulants as indicated. On the day of the procedure the patient arrives to an outpatient interventional radiology suite or ambulatory surgical center; moderate sedation or monitored anesthesia care is provided per institutional anesthesia assessment. Under CT or ultrasound guidance, the interventional radiologist advances a percutaneous RFA needle into the renal mass, performs thermal ablation of the lesion(s), and obtains post-ablation imaging to confirm adequate ablation zone and exclude immediate complications. The patient is observed in the recovery area; most patients are discharged the same day if stable, with follow-up imaging planned in 1–3 months to assess for residual tumor.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
50605 | Nephrectomy, partial, including partial ureterectomy, when performed; wedge resection of renal cortex | Occasionally considered as an alternative definitive surgical treatment for small renal masses when RFA is not appropriate |
77012 | CT guidance for needle placement (e.g., biopsy, aspiration, injection) | May be reported when CT guidance is used for needle placement during percutaneous RFA
76942 | Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection) | May be reported when ultrasound guidance is used for needle placement during percutaneous RFA
43246 | Biopsy of gastrointestinal tract; endoscopic, transgastric — (Note: unrelated; omitted)
76937 | Ultrasound guidance for vascular access — (Note: less applicable; omitted)
99152 | Moderate sedation services provided by the same physician performing the procedure (initial 15 minutes) — (Note: anesthesia/sedation codes vary) | Use when reporting moderate sedation by the physician per payer policy
99155 | Moderate sedation services, more complex — (Note: anesthesia/sedation codes vary) | Use if more complex moderate sedation is delivered and reported per payer policy
10022 | Fine needle aspiration; without imaging guidance | Not typically related — (Note: omitted)
76937 and other non-relevant codes were not included per instruction to not add unrelated codes.