CMS Pub. 100-03, ch. 1, § 230.1

CIM 35-81

Traditional approaches for the treatment of kidney stones are the surgical technique nephrectomy (or

nephrotomy) and endoscopic treatments via the urethra. In the last few years, several new approaches in the

surgical management of upper urinary tract kidney stones have been developed, among them invasive and

noninvasive lithotripsy techniques.

In addition to the traditional surgical/endoscopic techniques for the treatment of kidney stones, the following

lithotripsy techniques are also covered for services rendered on or after March 15, 1985.

A. Extracorporeal Shock Wave Lithotripsy

Extracorporeal Shock Wave Lithotripsy (ESWL) is a noninvasive method of treating kidney stones using a

device called a lithotriptor. The lithotriptor uses shock waves generated outside of the body to break up

upper urinary tract stones. It focuses the shock waves specifically on stones under x-ray visualization,

pulverizing them by repeated shocks. ESWL is covered under Medicare for use in the treatment of upper

urinary tract kidney stones.

B. Percutaneous Lithotripsy

Percutaneous lithotripsy (or nephrolithotomy) is an invasive method of treating kidney stones by using

ultrasound, electrohydraulic or mechanical lithotripsy. A probe is inserted through an incision in the skin

directly over the kidney and applied to the stone. A form of lithotripsy is then used to fragment the stone.

Mechanical or electrohydraulic lithotripsy may be used as an alternative or adjunct to ultrasonic lithotripsy.

Percutaneous lithotripsy of kidney stones by ultrasound or by the related techniques of electrohydraulic or

mechanical lithotripsy is covered under Medicare.

The following is covered for services rendered on or after January 16, 1988.

C. Transurethral Ureteroscopic Lithotripsy

Transurethral ureteroscopic lithotripsy is a method of fragmenting and removing ureteral and renal stones

through a cystoscope. The cystoscope is inserted through the urethra into the bladder. Catheters are passed

through the scope into the opening where the ureters enter the bladder. Instruments passed through this

opening into the ureters are used to manipulate and ultimately disintegrate stones, using either mechanical

crushing, transcystoscopic electrohydraulic shock waves, ultrasound, or laser. Transurethral ureteroscopic

lithotripsy for the treatment of urinary tract stones of the kidney or ureter is covered under Medicare.