Practice Management Alert

Question: I have an insurance company that is not paying for a code, stating it is bundled into another code. We are billing 52353, 52352-59, and 52332-59.

My doctor is doing a cystourethroscopy with ureterscopy and/or pyeloscopy with a holmium laser lithotripsy. He is then doing a basket extraction of multiple stone fragments, not just irrigating the stones out. Then he is placing a stent in the ureter.

The insurance company is saying the 52352 is part of 52353. My doctor is saying this is a different procedure though it is the same anatomical site. I haven't had any problems billing this way with at least three other major insurance companies, but now one payer is denying my claims. Is that payer correct to deny the claim?

Washington D.C. Subscriber

Answer: The payer is correct. As you know, the Correct Coding Initiative (CCI) bundles 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]) into 52353 (...with lithotripsy [ureteral catheterization is included]). You can unbundle the codes in certain circumstances -- for example, when your doctor does the two procedures on different sides. However, you should not, per CCI, be unbundling those two codes for the same side.

Clinically it makes sense that your doctor would feel these procedures are two separate procedures and there is more work involved. Unfortunately, CCI and coding rules don't agree. Payers feel that you're breaking up the stone and you have to take the fragments out somehow as part of the lithotripsy procedure. It doesn't matter how you take them out. You can't bill for the lithotripsy and the extraction separately on the same side.

If your doctor did the procedures on separate sides, you could bill 52353 and 52352 using the 59 (Distinct procedural service) modifier and the side modifiers: RT (Right side) and LT (Left side).

Watch out: You may see different payment policies with different payers, but any payer following CCI will follow this rule. Medicare especially should not be paying you on this. If you are billing a Medicare carrier using both codes and are getting paid, the carrier's system is most likely automatically assuming you have separate side documentation or there is an error in their system with this bundle. If the Medicare carrier ever asks for documentation to support these claims, you will be asked to repay any claims where you billed 52352 and 52353 together for the same side. Under CCI and Medicare rules, that is incorrect coding. You should stop billing that way as soon as possible.

Alternative: For third-party payers there may be different payment policies and they may not follow CCI rules. You should check your coding guidelines for your other payers. Any payer that follows CCI, however, will view this as incorrect coding. If they don't follow CCI and Medicare rules, you may be able to continue billing 52352 and 52353 on the same side.