Outpatient Facility Coding Alert

Question: Our physician performed a cystoscopy, a right retrograde pyelogram, and a right ureteroscopy with stent placement. In postoperative imaging, the stent was found to be incorrectly positioned. The patient returned to the operating room (OR) the next day for a stent removal. Should I report the stent removal? If so, do I report it with modifier 58 or 78?

Mississippi Subscriber

Answer: First, you’ll want to break the surgeries apart and report the respective CPT^® codes. For the cystoscopy with right retrograde pyelogram, you’ll report code 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic) with modifier RT (Right Side). You’ll report the right ureteroscopy with stent placement as 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)), also with modifier RT. No bundling edits exist with these codes, so you do not need to report an overriding modifier for the column 2 code.

Next, you’ll address the physician’s removal of the stent in the OR the next day. Since the stent was found to be incorrectly positioned, you can consider this a complication of the original surgery. You will report this service using code 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple). Additionally, you will append modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period) so as to inform the payer that this was a complication treated in the OR of a related procedure within the global period. 

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