Urology Coding Alert

Beware: All 'stents' are not created equal.

When your urologist places a stent following a ureteroscopic procedure, such as a stone removal, the coding isn't always cut and dry. You'll need to dig into the documentation details to ensure you choose the correct code for the clinical circumstances.

Take a look at these three pointers so you'll avoid the most common stent coding mistakes.

1. Learn When a Stent Isn't Really a Stent

Not every mention of "stent" in your urologist's documentation means you can report a stent code such as 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]).

Here's why: There are really two types of stents your urologist will use -- temporary and permanent -- and the first one is not really a true stent, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook, New York.

"A temporary stent is actually a ureteral catheter, placed at surgery to assist during surgery," Ferragamo says. "The urologist then removes the catheter after surgery, before the patient leaves the operating room. In this case, you should not report stent code 52332. Instead, report 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiological service)."

For example: When another surgeon, such as a gynecologist or colorectal surgeon, asks the urologist to place "stents" for ureteral identification and safety during a complex surgical procedure (and those "stents" are removed at the end of the procedure), they are not true stents. They're actually ureteral catheters. "You should report 52005, not 52332 for these procedures," Ferragamo says.

Warning: 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 "stent" insertion may not be appropriate. You could use the reason for the primary surgery, such as diverticulitis (562.10-562.13).

However, remember that there are some payers that 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. In these cases bill the diagnosis code 591 (Hydronephrosis) as the primary diagnosis and V07.8, (Other specified prophylactic or treatment measure) as the secondary diagnosis. This sequencing of diagnostic codes indicates that the ureteral catheter has been inserted prophylactically to avoid hydronephrosis.

2. Stick With 52332 for Postoperative Drainage Stents

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,Ferragamo says.

While temporary stents that are often placed as part of an endoscopic procedure (52320-52355) cannot be reported in addition to 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.

Here's how: When your urologist documents that he placed a double-J stent for postoperative drainage, you should report 52332.

Bilateral coding: If your urologist places bilateral double-J stents for postop drainage, your exact coding will depend on the payer. For Medicare, report 52332 with modifier 50 (Bilateral procedure) appended. Private payers may also want 52332-50 or they may request you use 52332-LT (Left side) and 52332-50-RT (Right side) on two lines.

3. Separately Report Stent Placement In Many Cases

If your urologist places a stent during the same session in which he also performs another ureteroscopic procedure, you can most likely separately report both procedures.

 "When the patient has a large ureteral stone which the urologist removes ureteroscopically, there may follow a significant amount of ureteral swelling," Ferragamo explains. "To avoid complete ureteral obstruction, an indwelling ureteral stent may be placed to keep the ureter open."

For this case, bill the ureteroscopy code (52352, Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]) and 52332. For some payers you may need to append modifier 51 (Multiple procedures) to 52332 to indicate that you have performed a secondary procedure. You do not need to append modifier 59 (Distinct procedural service), because 52332 is no longer bundled with 52320-52355.

Example: A patient has a stone lodged in the ureter, which your urologist discovers by performing a retrograde pyelogram in the hospital. Then, the urologist manipulates the stone into the kidney pelvis to afford the patient pain relief, and plans in the near future to do an extracorporeal shock wave lithotripsy (ESWL). After manipulating the stone, your urologist inserts a double J stent to hold the stone within the kidney pelvis.

For the retrograde pyelogram, report 74420 (Urography, retrograde, with or without KUB). Append modifier 26 (Professional component) to the 74420, since your urologist read and interpreted the x-ray, but the hospital owns the equipment. Leave off 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) because CCI bundles that code with the next two codes you will report.

Report 52330 (Cystourethroscopy [including ureteral catheterization]; with manipulation, without removal of ureteral calculus) for the manipulation of the ureteral stone back into the renal pelvis. Finally, report 52332 for the stent placement.

ESWL: You'll use 50590 (Lithotripsy, extracorporeal shock wave) when the patient undergoes the ESWL at another session.

"When a patient undergoes an ESWL and the placement of a double J stent at the same encounter, you may separately report both the ESWL and stent insertion using 50590 and 52332," Ferragamo says. There is no Correct Coding Initiative (CCI) bundle between 52332 and 50590 (Lithotripsy, extracorporeal shock wave) so you don't need a modifier. You may need to append modifier 51 (Multiple procedures) if your payer uses that modifier.