Overview 

Upper Tract Urothelial Cancer (UTUC) is a rare malignancy occurring in the lining of the upper urinary tract, involving the renal pelvis and ureters. Accurate documentation, coding, and billing are essential for ensuring proper reimbursement, compliance, and optimal patient management.

Patients with either newly diagnosed or recurrent upper tract urothelial tumors are first evaluated for endoscopic manageability. Based on that assessment, treatment options are as follows:

• If the tumor is endoscopically manageable (either low- or higher-volume, and whether unifocal or multifocal):

  • Visible disease is resected or ablated through endoscopic procedures.

  • Post-resection, chemoablation is used:

    • JELMYTO is administered once weekly for six weeks.

    • This approach is designed to treat any residual disease that may remain after visible tumor resection.

• If the tumor is unresectable via endoscopic means:

  • Chemoablation is initiated directly without resection.

  • The goal in this case is to spare the kidney by treating the unresectable disease in a non-surgical manner using JELMYTO.

Additional Resources from UroGen

(PRS Vetted and Approved)

How to Bill Jelmyto Guide

Billing and Coding Guide

Prior Authorization Checklist

Claims Submission Checklist

Appeals Letter

Physician Office Coding

CPT and HCPCS Codes:

Billing, coding, and reimbursement for JELMYTO® (mitomycin) for pyelocalyceal solutions

Retrograde approach using cystoscope

Antegrade approach via nephrostomy tube

ICD-10 Codes:

Documentation for Reimbursement Tips

If billing for Jelmyto make sure you include the amount used and the amount discarded.  This information has been a target of the Recovery Audit Contractor (RAC) audits.