Living Donor Nephrectomy (Laparoscopic)
5054750320wRVU: 21.87 — Open living donor nephrectomy (21.87 wRVU, 90-day global; use instead of 50547 for open approach)50325wRVU: 0.0 — Backbench standard preparation of living donor renal allograft (billed by recipient surgeon/team; distinct from 50323 which is for cadaveric donors)50327wRVU: 3.9 — Backbench venous anastomosis reconstruction of renal allograft, each (3.90 wRVU; billed by recipient team for venous extension grafts)50328wRVU: 3.41 — Backbench arterial anastomosis reconstruction, each (3.41 wRVU; billed by recipient team for multiple arteries or arterial reconstruction)50329wRVU: 3.26 — Backbench ureteral anastomosis reconstruction, each (3.26 wRVU)
Living kidney donor: [related / unrelated / paired exchange]
Same
Laparoscopic [hand-assisted] left [/ right] donor nephrectomy
[Attending name], MD
[Fellow/Resident name]
General endotracheal
Patient is a [related / unrelated] living kidney donor for recipient [initials / MRN]. Donor evaluation complete: ABO compatible, cross-match negative, GFR [X] mL/min, split function [X%] left / [X%] right. Left kidney selected for donation [/ right selected due to anatomy]. No donor comorbidities precluding donation. Risks including bleeding, ureteral injury, conversion to open, hernia, and long-term single-kidney function discussed at length. Independent donor advocate involved. Consent obtained.
Left kidney with single renal artery and single renal vein. [Accessory lower pole artery identified and managed.] Ureter [adequate length to pelvis]. Kidney [appeared healthy, pink, and well-perfused].
The patient was positioned in the right lateral decubitus position with the left side up, kidney rest elevated. The left flank was prepped and draped in sterile fashion.
A [12-mm / 5-mm] port was placed at the umbilicus using [optical trocar / Veress needle / Hassan technique] with CO2 insufflation to 15 mmHg. Additional [3 / 4] ports placed in the left flank under direct vision. [A hand-port was placed at a [7 cm] left lower quadrant incision.]
The left colon was mobilized along the white line of Toldt. The spleen and pancreatic tail were mobilized medially. The renal hilum was dissected. The gonadal vein was ligated and divided. The adrenal vein was [preserved / ligated and divided]. The ureter was dissected to the level of the iliac vessels with a generous periureteral tissue pedicle. The renal vein and artery were each dissected free circumferentially and prepared for division.
Prior to vascular division, IV [mannitol [X] g / furosemide [X] mg] was administered to promote donor diuresis and protect residual renal function. The ureter was clipped and divided distally. IV heparin [X units] administered. The renal artery was clipped [x2 proximal clips] and divided with [locking clips / endovascular stapler]. The renal vein was clipped [x2] and divided with [locking clips / endovascular stapler]. The kidney was removed through the [hand-port / Pfannenstiel / lower quadrant] extraction site in a laparoscopic bag.
Kidney passed to back-table team; [immediate perfusion with cold preservation solution, excellent perfusion of parenchyma]. Total warm ischemia time: [X] minutes.
Hemostasis confirmed. Fascial port sites [12 mm and extraction site] closed with figure-of-eight [0-Vicryl]. Skin closed. Patient tolerated the procedure well.
None
Left kidney passed to back-table for transplantation
Minimal
None
Patient extubated in OR. Taken to PACU. Discharged POD 2-3.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Living kidney donor: [related / unrelated / paired exchange]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic [hand-assisted] left [/ right] donor nephrectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX who is a [related / unrelated] living donor for recipient [initials]. Donor evaluation complete; ABO compatible; cross-match negative; GFR *** mL/min; [left / right] kidney selected. Independent donor advocate involved. Risks including bleeding, ureteral injury, open conversion, and long-term single-kidney status discussed. Informed consent obtained.
FINDINGS: [Left / right] kidney with [single / double] renal artery and single renal vein. [Accessory lower pole artery identified and managed.] Adequate ureteral length. Kidney appeared healthy and well-perfused.
DESCRIPTION OF PROCEDURE:
Patient right lateral decubitus. Left flank prepped. Umbilical 12-mm port placed; CO2 to 15 mmHg; additional ports under direct vision. [Hand-port placed at LLQ.] Left colon mobilized along Toldt; spleen and pancreatic tail reflected medially. Renal hilum dissected; gonadal vein ligated and divided; adrenal vein [preserved / divided]. Ureter dissected to iliac vessels with periureteral pedicle. Ureter clipped and divided. IV [mannitol / furosemide] given for donor diuresis. IV heparin *** units given. Renal artery clipped x2 and divided; renal vein clipped x2 and divided. Kidney extracted via [hand-port / Pfannenstiel / LLQ] in endo-bag; warm ischemia time *** minutes. Immediate back-table perfusion confirmed. Hemostasis confirmed. Fascia closed at 12-mm and extraction sites. Skin closed. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Left kidney to back-table for transplantation
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to PACU. Anticipated discharge POD 2-3.
Signed: .ME, .MYDEGREE
.TODAYVariants
Right donor nephrectomy
Right renal vein is shorter, requiring more careful dissection and sometimes an IVC patch. Document vein length and whether extension with donor iliac vein was needed. Right side selected when anatomy favors it (multiple left arteries, right dominance).
Open donor nephrectomy
CPT 50320 (21.87 wRVU) — NOT 50300 (50300 is cadaveric donor nephrectomy and is not payable under the physician fee schedule). Flank incision or midline. Increasingly rare; reserved for difficult anatomy or failed laparoscopic approach. Document conversion rationale if open after laparoscopic attempt.
Charting Tips
- Document first warm ischemia time (from vascular clamp application to initiation of cold perfusion on the back table) as a specific number — use seconds for short times, not 'minimal.' This is distinct from second warm ischemia (anastomosis time during implantation, documented by the recipient team). First warm ischemia time cannot be reconstructed after the fact and is a mandatory OPTN data element.
- Document vascular anatomy in detail: number of renal arteries, artery and vein length achieved, and how any accessory vessels were managed. The transplant surgeon plans bench reconstruction from your note.
- State that the ureter was mobilized with its periureteral fat pedicle intact and document the length achieved. Ureteral ischemia is the leading cause of urologic complications after transplant.
- Document the donor's urine output at case conclusion and whether the remaining kidney appeared to compensate. This is the intraoperative record of single-kidney function.
- Document heparin dose, time given, and time from heparin to clamp. This is a donor safety record, not a transplant logistics note.
- Any intraoperative deviation — capsular tear, bleeding, accessory vessel injury — must be documented completely. This is elective surgery on a healthy person. There is no acceptable undocumented complication.
- OPTN Policy 18.5 requires the transplant center to collect and report living donor follow-up data at 6 months, 1 year, and 2 years post-donation (creatinine, urine protein, blood pressure, clinical status). These reporting windows are defined and must be submitted within them. The operating surgeon is frequently the provider documenting these visits — structure follow-up notes to capture all required elements.
Billing Tips
- Bill 50547 for laparoscopic living donor nephrectomy (hand-assisted or pure laparoscopic, 25.68 wRVU, 90-day global). Bill 50320 for open living donor nephrectomy (21.87 wRVU). Note: 50300 (cadaver donor nephrectomy) is not payable under the physician fee schedule; it is covered via organ acquisition charges (OPO standard acquisition charge). The laparoscopic approach does not require a modifier, as 50547 is the specific laparoscopic code.
- The donor's surgical care is billed separately from the recipient's transplant. Two separate surgeons (or the same surgeon on two separate claims) bill for the donor operation and the recipient implantation. Both are covered under the recipient's insurance as part of organ procurement.
- Hand-assisted laparoscopic donor nephrectomy (HALDN) uses the same code as pure laparoscopic (50547). Document hand-port use in the operative note but code selection does not change.
- Donor follow-up within 90 days (wound check, blood pressure monitoring, renal function labs) is included in the 90-day global. Donor evaluation, workup, and preoperative visits are separately billed and typically covered under the recipient's insurance through the transplant center.
- Backbench preparation of the living donor kidney is performed by the recipient team and billed by them as 50325 (backbench standard preparation of living donor renal allograft). Additional backbench reconstruction is billable as 50327 (venous, each; 3.90 wRVU), 50328 (arterial, each; 3.41 wRVU), or 50329 (ureteral, each; 3.26 wRVU). Note: CPT 50323 is the cadaveric donor backbench code — do not use 50323 for living donor backbench. If a donor complication requires reoperation (e.g., bleeding, conversion to open), bill the specific reoperation code (e.g., 49000 for exploratory laparotomy) with modifier -78 if within the 90-day global period of 50547.
General coding reference. Verify with your institution’s billing department before submitting claims.