Urology Coding Alert

Urologists frequently perform more than one procedure during a session, but they may not be receiving all the payment to which they are ethically entitled. To solve this problem, they should make sure to bill for all the services provided, which requires thorough documentation of each procedure.

For example, a 28-year-old woman has a one-week history of left flank pain, and a CT scan reveals a 6-mm left distal ureteral calculus. The preoperative diagnosis is left ureteral calculus, which is also the postoperative diagnosis. The operation consisted of a cystourethroscopy, left ureteral catheterization with left retrograde pyelography, left ureteroscopy, Swiss lithotripsy, stone basket extraction and insertion of an indwelling left double J stent.

During the procedure, the patient was administered general anesthesia, placed in the dorsal lithotomy position, and prepped and draped in a sterile environment. A 22 French Storz cystoscope with a 30-degree lens was then advanced. The urethra was noted as normal. The bladder was also normal, without stones, papillary tumors or other abnormalities. The left ureteral orifice was cannulated with a 5 French open-ended catheter, and a left retrograde pyelogram was performed. This demonstrated a filling defect just proximal to the extramural ureter, consistent with the 6-mm stone.

At this point, a guide wire was passed through the ureteral catheter up to the level of the renal pelvis, the ureteral catheter was removed, and balloon dilation of the ureteral orifice was performed. Following this, the cystoscope was removed leaving the guide wire in place. A 9 French tapered Wolfe rigid ureteroscope was advanced, and a calculus was identified within the distal ureter. This was grasped in a four-wire basket and pulled to the level of junction of the extra and intramural ureter, but the stone could not be brought within the intramural ureter. Therefore, the basket was disengaged, and the Swiss lithotripsy probe was advanced because the stone was fragmented within the basket. At this point, the largest fragment remaining was removed from the basket.

There were no complications with this portion of the procedure. With the stone adequately fragmented within the ureter, the ureteroscope was withdrawn. The guide wire was back loaded onto the cystoscope, and a 6x24-cm left double J stent was advanced and coiled within the left renal pelvis. This was confirmed fluoroscopically. In addition, a J hook of stent was protruding from the left ureteral orifice, which was confirmed visibly. The bladder was emptied, and the cystoscope was removed. The patient was then extubated and transported to the recovery room in stable condition.

Coding the Procedure

The main procedure and the first on the claim form should be coded 52337 (52353 in 2001) for cystourethroscopy, with ureteroscopy and/or pyeloscopy; [...]