Question: Which code is correct for suprapubic cystoscopy with stone removal?
West Virginia Subscriber
Answer: You should report 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; complicated [APC 0162]) for the cystoscopy via the cystotomy opening with removal of a large stone or multiple stones.
If the physician actually performed a simple extraction of a single small stone instead, report 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple [APC 0161]).
You should also report 51705 (Change of cystostomy tube; simple [APC 0164]) for the cystostomy tube change, if performed. Be aware that multiple-procedure reductions may apply to 51705 because the physician also performed the cystourethroscopy during the same session.
-- Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
