Urology Coding Alert

Tip: Details matter to ensure proper code selection. 

Percutaneous nephrostomy is a commonplace procedure in most urology practices, but the coding for removal of a post procedure nephrostomy tube may be a bit more complicated. Do you know how to tackle a removal procedure, selecting the right codes for your urologist’s work without missing any key components, especially when an ileal conduit is also present? 

Test your knowledge with this scenario based on a real-life case from Jo Ann Hawtrey, MA, CPC, CUC, certified medical coder for the University of Iowa Hospitals and Clinics/Patient Financial Services in Iowa City. 

Overview: This case involves a patient with an ileal conduit and bilateral uretero-enteric anastomotic strictures at the conduit level. The patient is presently being managed with bilateral nephro-ureteral-conduit indwelling stents. In this particular case, the urological procedures include looposcopy and antegrade removal of the nephro-ureteral stents, ureteroscopy, endo-urological dilation of the strictures, and bilateral placement of ureteral stents.

Operative report: The patient’s abdomen surrounding the ileal conduit in the RLQ was prepped and draped in the standard sterile fashion. A flexible cystoscope was navigated into the ileal conduit and the distal ends of bilateral (two) percutaneous nephro-ureteral catheters were seen to curl within the ileal conduit. Sensor wires were advanced up to the renal collecting systems bilaterally alongside the catheters.  Each nephro-ureteral catheter was then cut at the back (flank), grasped within the conduit under vision and removed under fluoroscopy, taking care to leave the wires in good position. A flexible ureteroscope was advanced over the wire into the left collecting system. Visualization was suboptimal, but no concerning lesions, papillary tumors, or calculi were seen within the renal pelvis nor down the length of the ureter. Both uretero-enteric anastomoses were then balloon dilated under direct cystoscopic visualization. 6 x 28 cm ureteral stents were then advanced over both wires and seen to curl in the kidneys fluoroscopically and in the conduit under direct cystoscopic (looposcopy) visualization. 

Coding solution: Try coding this case yourself and then review the guidance below to see if your coding matches the experts’.

Start With the Ureteroscopy

The first code you’ll report will be for the ureteroscopy via an ileal conduit. Use 50951 (Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) for this procedure, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

The important point that leads you to code 50951, is that your urologist performed this endoscopic procedure through an established ileal conduit with the ureteral orifice in the proximal portion of the conduit as an established ureterostomy, Ferragamo explains.  

Update Your Ileoscopy Coding

Next, you should report 44384 (Ileoscopy, through stoma; with placement of endoscopic stent [includes pre- and post-dilation and guide wire passage, when performed]) for the ureteral dilation. “This code may be used for visual endoscopic placement of wires or change of ureteral stents or catheters directly through an ileal conduit,” Ferragamo says.

Remember: CPT® 2015 deleted ileoscopy code 44383 (Ileoscopy, through stoma; with transendoscopic stent placement [includes predilation]). In its place, you have 44384, which properly describes  the procedure your urologist performed, says Christy Shanley, CPC, CUC, billing manager for the department of urology at the University of California, Irvine. 

Additionally, 44384 represents both unilateral and bilateral procedures. That means that even though your urologist performed the dilation on both sides, you should only report 44384 once, not twice by using modifiers RT (Right side) and LT (Left side) or modifier 50 (Bilateral procedure).

Tackle Substitute Bladder with 52315

Since the conduit is acting as a substitute bladder, you should use 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; complicated) for the endoscopic removal of the distal ends of the nephro-ureteral catheters from the conduit. Choose 52315 rather than 52310 (... simple) because these tubes are often encrusted with mucous from conduit secretions and often are more difficult to remove, Ferragamo says.

Modifier help: Since your urologist performed an ileoscopy and not a cystoscopy, add modifier 52 (Reduced services) to 52315. This shows the payer that while 52315 is the best code to represent the procedure your urologist performed, he did not perform the complete surgery as described for that procedure in the code’s descriptor, explains Elizabeth Hollingshead, CPC, CUC, CMC, CMSCS, office/billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio. 

Consider nephrostomy tubes as foreign bodies that the urologist is removing. Therefore, 52135 fits. Do not report 50389 (Removal of nephrostomy tube, requiring fluoroscopic guidance [eg, with concurrent indwelling ureteral stent]), since that code usually represents removal of a nephrostomy tube from the flank.   

Capture Stent Placement

Finally, the last code you’ll report for this case is 50688 (Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit). This code represents the endo-urological replacement of the stents via an ileal conduit.

Note: You should not report the stent placement using 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [eg, Gibbons or double-J type]). 

Code 50688 represents both unilateral and bilateral procedures, just like 44384, so even though your urologist placed bilateral stents, you should only report 50688 once, without modifiers RT, LT, or 50.