Medicare Compliance & Reimbursement

Background: Part B Medicare Administrative Contractor (MAC) CGS Medicare reviewed 108 claims for urinary stent placement code 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)). The payer found a startling 59.3 percent error rate among these claims, with the biggest denial reason being no documentation of medical necessity.

You can avoid denials for your stent placement services by checking out a few key pointers that can help you avoid stent coding mistakes.

Differentiate Stent From Catheter

Some urologists use the terms catheter and stents interchangeably. However, just because the urologist documents a stent placement, you aren’t necessarily entitled to report 52332 or another stenting code. Make sure the documentation supports the coding.

Why? Even when the physician uses the word “stent” in the documentation, there are instances when they’re referring to a catheterization and not stenting. The difference in the documentation may lie in how long the patient is expected to have the device in place.

From a coding perspective, a temporary stent is reported with codes for a ureteral catheter placement. These are typically placed into the patient’s urethra prior to surgery, and are then removed following the procedure. A true stent, on the other hand, stays in place much longer than a catheter, and the urologist may document that the stent is a “permanent” one to differentiate it from catheterization.

If you discover that the urologist documented catheterization instead of more permanent stenting, you’d instead report 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service).

Check this clue: One factor that might provide you with a hint that the physician performed catheterization and not stenting is if the documentation indicates that the urologist inserted the device at the request of a provider in another specialty, and the diagnosis codes don’t describe actual urological symptoms or findings. In the absence of a urological diagnosis such as N13.9 (Obstructive and reflux uropathy, unspecified), it’s likely that the physician inserted a temporary catheter and not a stent.

It’s important to note that some insurers won’t pay for the services of a urologist for a simple catheter insertion (such as 52005) if a urological diagnosis isn’t present unless you document the fact that the urologist was involved due to a concern about the patient developing hydronephrosis. If that occurs, you may need special diagnosis code sequencing when reporting 52005, based on your carrier’s requirements.

Maintain Urinalysis or Culture Documentation

Code 52332 pays about $408 when you perform it in the office, and $155 when it’s done in a facility — but many urologists lose this pay due to denials, all because of missing documentation.

Here’s why: During a recent CGS Medicare review of claims for 52332, the payer found that “crucial information about medical necessity is often missing from ureteral stent insertion documentation. The major area of concern in reviews of these services is that results from urinalysis or urine culture performed prior to the procedure are not provided in response to an Additional Documentation Request (ADR).”

Explanation: Most payers want the urologist to have the results of a recent urinalysis or urine culture documented to confirm that the patient is free of infection prior to the stent placement. If an infection is found, the urologist can prescribe antibiotics to reduce the chances of post-stent placement complications and potentially shorten the length of the patient’s hospital stay.

In addition to the urinalysis documentation, you should also maintain the following in the patient’s record to demonstrate medical necessity for 52332:

• The diagnostic workup, tests, and plan for the ureteral obstruction diagnosis
• The operative report showing details of how the stenting was performed
• Fluoroscopic verification of adequate stent placement (if the patient was pregnant, then ultrasound documentation should suffice)

Best practice: Ask your payer for a list of documentation requirements for this service so you know which types of records you should maintain in the patient’s file. Each insurer may have slightly different regulations and you want to retain the correct records and submit them when asked.

‘Permanent’ May Not Mean Forever

Although coding conventions refer to stenting as “permanent” for coding purposes, that nomenclature simply allows you to differentiate the stent described in 52332 from a catheter that’s placed just for the length of surgery.

In reality, the stents placed using code 52332 do stay with the patient for a set period of time, but they are typically removed eventually. They are often placed for postoperative drainage (which is usually the case with a double-J stent) and stay in place until the urologist determines that it’s safe to remove the stent.

In Some Cases, You Can Separately Report Other Procedures

If your urologist places a stent during the same session in which they also perform another ureteroscopic procedure, you may be able to report both procedures together.

Example: Suppose the patient has a large ureteral stone, which the urologist removes ureteroscopically. The urologist then observes a significant amount of ureteral swelling. To avoid complete ureteral obstruction, the urologist decides to place an indwelling ureteral stent to keep the ureter open.

For this case, bill the ureteroscopy code (52352, Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)) and 52332. Because the National Correct Coding Initiative (NCCI) doesn’t bundle these codes together as of the third quarter of 2023, you do not need to append modifier 59 (Distinct procedural service).

Always check the NCCI edits before reporting 52332 with another procedure, because it may be bundled into certain surgeries.