Ob-Gyn Coding Alert

You Be the Coder:

Prophylactical Placement of Ureteral Stents

Published on Thu Mar 14, 2024

Question: If the ob-gyn places catheters for identification of the ureters (52005) during a gyn procedure —usually a hysterectomy — and then removed them at the end of the procedure, is 52005 billable?

I had thought the National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) manual stated that it was not billable if only done for this purpose, but maybe I was wrong, because I only see 52005 and 52332 when billed together addressed.

We have some physicians that are wanting to bill for this procedure in addition to hysterectomy, as there is no NCCI edit. The only reference we have to counter that is an American Hospital Association (AHA) clinic, which usually applies to the hospital setting and not physician billing.

I also thought that since there was not a urological diagnosis to support medical necessity that it might not be billable, but the argument on that end is to leave that up to the payer to decide.

Are there any guidelines or CPT^®Assistant articles that relate to this issue?

New Jersey Subscriber

Answer: Per the American Urological Association (AUA) (AUA Update Series Lesson 11 Volume 39 2020), the use of stents prophylactically seems to add a slight amount of time to the surgical procedure with minimal complications and, although the overall low incidence of ureteral injury may not be lowered significantly by stent placement, early detection appears to be an advantage if injury does occur. With greater surgeon experience, iatrogenic injury rates decrease. The choice for prophylactic ureteral stenting is a surgeon preference based on multiple variables including complexity of case, anatomy, and experience.

That said, you technically could bill 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) for this prophylactic procedure, but keep in mind that this code was never added to CPT^® for this purpose. The clinical vignette describing the physician work used to add the code to the CPT^® book is as follows:

Turn on video monitors. Be sure all personnel are safely in lead aprons. Place flexible cystoscope. Inspect entire bladder. Locate ureteral orifice. Order indigio carmine to be administered IV and wait 5 minutes for the efflux. Insert flexible wire up the ureter and confirm fluroscopically. Pre irrigate an open ended ureteral catheter and advance over the wire. Remove wire. Inject the ureteral catheter with contrast and obtain radiographs or digital images. Assess the images for completeness and possibly reinject. Remove catheter and reinspect bladder for any damage. Drain bladder and remove endoscope.

Please be sure that your provider is documenting this part of the procedure completely — and it would also be helpful to add a note as to why it is medically necessary for this patient.

If you bill this code, you should not append modifier 50 (Bilateral procedure) because the basic procedure is an examination of the bladder and urethra (cystourethroscopy), which are not paired organs. The work relative value units (RVUs) assigned take into account that it may be necessary to examine and catheterize one or both ureters.

So, as a coder, you must ask yourself: “Is a diagnostic cystourethroscopy being performed and documented as such?” A statement like “scope placed” will not work, and there should be some description of the bladder and urethral findings.

If you do bill 52005, your diagnosis code will have to be Z40.8 (Encounter for other prophylactic surgery) unless you can also report an underlying medical need for the patient (such as previous surgical injury, presence of adhesions, etc., to further back up the need). Pull whatever details you can from the operative report and medical record to explain what your ob-gyn did and why.

Linking the diagnosis for the reason for the gyn surgery will get you a denial for medical necessity. If you look at any surgical text, you will clearly see that identification of the ureters is integral to any gyn procedure, so you may find that most payers consider the use of prophylactic ureteral catheters to prevent damage to be part of the procedure. Even the American College of Obstetricians and Gynecologists (ACOG) coding manual has in the past stated that insertion of stents and catheters during a procedure is included.