Urology Coding Alert

Hint: You can’t report 52332 whenever your urologist places a ‘stent.’ 

Stent placement is routine practice for urologists and you may even report the associated placement codes more than most other urology codes. Not only does your urologist place stents during his own procedures, but likely other surgeons call your provider into the OR occasionally for stent placements. Those clinical scenarios are the ones that trip up many coders.

Take a look at this sample scenario to ensure you don’t fall victim to the pitfalls of stent coding.

Explore the Case

Review this sample clinical situation from reader Andrea O’Daniels, KSI medical coder at Healtheast/St. Joseph Hospital in St. Paul, Minn.: “Our surgeon was asked to place bilateral catheter for surgical aid for another physician. Then our physician removed the stent at the end of the surgery.”

Coding dilemma: “Do I just use 52332 -50 or is there a CPT^® code for just surgical aid?” O’Daniels asks.

Differentiate Between Stents and Catheters

When you see “stent” in your urologist’s documentation that doesn’t mean you can report a stent code such as 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) or 52332-50 (Bilateral procedure) if the urologist does the procedure on both sides.

Here’s why: There are really two types of “stents” your urologist will use — temporary and permanent. The first, temporary stents aren’t actually stents at all. A temporary stent is actually a ureteral catheter, placed during surgery and then usually removed by the urologist after surgery, before the patient leaves the operating room as in O’Daniels’s case.

If your urologist placed ureteral catheters not stents, as in this scenario, you wouldn’t use
52332-50, says Elizabeth Hollingshead, CPC, CUC, CMC, CMSCS, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio. Instead, report 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiological service).

How it works: When another surgeon, such as a gynecologist or colorectal surgeon, asks the urologist to place “stents” for ureteral identification and safety during a complex pelvic surgical procedure (and those “stents” are removed at the end of the procedure), they are not true stents. They’re actually ureteral catheters, such as “whistle” or “olive” tipped ureteral catheters.

“Our urologists are often called into surgery to place a ‘stent’/ureteral catheters (52005) prior to surgery,” says Christy Shanley, CPC, department administrator for the University of California, Irvine department of urology. “They are meant to protect/ identify the ureter during surgery. They are removed after the procedure is completed. I believe ‘true stents’ (52332) are left in for a period of time, and are either exchanged (52332) or removed cystoscopically (52310, Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple).”

Know What Warrants 52332

The second type of stent is a “permanent” stent. These types of stents are placed after surgery for drainage, and are indwelling and self retaining. The patient leaves the operative room with the stent in place, and the stent will be removed at a later date.

While temporary stents that are often placed as part of an endoscopic procedure (52320-52355) cannot be reported in addition to the primary procedure because they are bundled with the primary procedure, an indwelling stent, which is placed during the procedure to keep the ureter open and to assist recovery after the procedure, can be billed separately.

When your urologist documents that he placed a double-J stent for postoperative drainage, you should make sure to also report 52332.

Watch Out for Diagnosis Troubles

Once you determine what procedure code to report and which modifiers you need to attach, your next trick is deciding on the associated diagnosis code. “My understanding is that a V code can’t be used as primary,” O’Daniels says. “So, do I list the reason for surgery as the primary? The diagnosis is diverticulitis.”

Often in these cases there are no urological symptoms or findings (such as 593.4, Other ureteric obstruction) mentioned in the body of the operative report. Therefore, trying to use a urological diagnosis for the temporary stent insertion may not be appropriate. You could use the reason for the primary surgery, such as diverticulitis (562.10-562.13). Some payers, including CMS, have suggested following this coding methodology of using the primary surgical diagnosis used by the general surgeon as your primary diagnosis as well.

Problem: Some other payers, however, will not reimburse for 52005 without a urological diagnosis and will not accept an intestinal diagnosis, such as 562.10, as the reason for the procedure.

Option 1: You should use V07.8 (Other specified prophylactic or treatment measure) as your primary diagnosis and the reason for the surgery as a secondary.

“You can use V-codes as primary and they are reimbursed,” explains Sally Kouw, CPC, billing coordinator with HH Service-Bates/Urology in Holland, Mich. “In this instance, you would use the V07.8.”

You can review the ICD-9 diagnosis coding guidelines in your ICD-9 manual, Kouw says. The guidelines explain that you can use V codes as primary diagnosis codes on a claim, she explains. According to the ICD-9-CM Official Guidelines for Coding and Reporting, “V codes may be used as either a first listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter.”

Option 2: You can also bill the diagnosis code 591 (Hydronephrosis) as the primary diagnosis and V07.8 as the secondary diagnosis. This sequencing of diagnostic codes indicates that the ureteral catheter has been inserted prophylactically to avoid hydronephrosis. Some experts, including Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York at Stony Brook, feel that this option is best. “Option 2 is the most accurate and the more likely acceptable diagnoses by most carriers,” Ferragamo says.