# Litholapaxy and lithotripsy



## tlm5506

Hello.
Hoping I can get help with this procedure. Here is the op note dictation:

The 25 French cystoscope was passed under camera vision. No anterior urethral abnormalities were identified. There was mild prosthetic regrowth. There was now wide core vesical neck contracture. The urinary bladder was entered. The right and left ureteral orifices were in normal position. There is a large brown bladder calculus measuring approximately 2cm. There is a bladder diverticulum lateral to the ureteral orifice with a large papillary bladder tumor which coated the lining of this diverticulum. No other bladder tumors were identified. Next Ellik irrigation was used to irrigate out the organized clots. This aided visualization as things were reinspected. Next the Holmium laser with 1000 fiber was used at predominately power level 1200 at 10 hertz and stone dissolution was achieved. Ellik irrigation and a pistons syringe were used to evacuate the stone fragments which were sent to pathology. Next the 26 French resectoscope was passed and the bladder diverticulum tumor was resected. Care was taken not to perforate the thin diverticula wall. The right ureteral orifice appeared patent and separate from the resection. The roller ball electric was passed and the diverticulum lining was coagulated with the roller ball for hemostasis. The bladder tumor chips were evacuated and sent to pathology. The bladder was drained with a 26 three way Foley catheter for continuous bladder irrigation.

My problem is this: in the Title of Procedure the doctor stated, "Cystolitholapaxy with laser lithotripsy to help the bladder stone and TURBT large."
I cannot find any documentation to support using the cystolitholapaxy code 52317. But if I can use it, then would it be appropriate to bill the lithotripsy 52353 and the cystolitholapaxy 52317? 
The codes that were chosen were:
52240
52353
52317-59
52001-59
I just don't think that these are the right codes.
Any help would be appreciated.
Thanks.


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## nateich

As this note is I would code as below, supporting documentation in quotation

*52317* "Holmium laser with 1000 fiber was used at predominately power level 1200 at 10 hertz and stone dissolution was achieved" using lithotripsy in the bladder
*52334 *"Next the 26 French resectoscope was passed and the bladder diverticulum tumor was resected"  No dimension was given, I personally would go back to physician and ask for an amendment to the op note, otherwise the lowest size is given
*52001-59* "irrigation was used to irrigate out the organized clots"

The physician did not use the ureteroscopy (52353) as he/she did not go into the ureter or kidney.


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## emcee101

Agree with stated documentation for 52317 by nateich. 

The second code should be 52224 not 52334 (cysto, insertion of ureteral guidewire to establish perc. neph., retrograde). Since your doctor did not state s specific size (only says large, which can vary *greatly* from one doctor to another) you cannot code for a large or medium TURBT. I would reccomend that you have the doctor write an addendum to the op note giving you a specific tumor size so that you can code to the actual size of the tumor. 

I would not code the 52001 since it is bundled into 52224 and is not a distinct and separate service. It was done to facilitate another service being done (used for proper visualization) and therefore should remain bundled. 

Code 52240 is not appropriate for the same reason as 52234 is not. Without a specific size you cannot code for a medium or large tumor. Get the addendum and educate your provider(s) on the need for size values in all op notes that are coded based on size.


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## nateich

To further clarify and I do appreciate emcee101 opinions:

52224 should not be used "fulguration with a biopsy" because the surgeon states a resection was done, I would ask for the size as I mentioned in order to give full credit otherwise you must default to smallest measurement 52234 *(obvious typo on my first post, my apologies) * and thank you for pointing that out 

I would add 52001-59 since removal of the clots does take additional time and was performed in order to visualize the stones clearly and 52001 is not bundled with 52317 

just my thoughts....


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