Urology Coding Alert

Hint: You won't always be able to report the procedures in the same order.

When your urologist fragments more than one stone located in two different locations within the urinary tract during one operative session, the proper coding might leave you scratching your head: Can you ever report both procedures? If you can, how do you sequence the codes? Tackle these tough questions by reviewing a sample scenario and learning the truth behind two common stone procedure myths.

Scenario: Your urologist performs a ureteroscopic laser lithotripsy of a left ureteral stone and lithotripsy of a bladder stone. How should you code these procedure performed during one operative session?

Separately Report Procedures Based on Anatomy

Myth: You can never separately report multiple stone fragmentations your urologist performs during the same operative session.

Reality: Depending on where the stones are in the urinary tract, you may be able to separately report and be paid for multiple fragmentation procedures during the same session. For a ureteroscopic fragmentation of a ureteral or renal pelvic stone your urologist performs, you'll report 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]). Remember that 52353 applies to "any type of fragmentation, whether you use a Holmium laser, a Candela laser, a mechanical lithotripsy, or an ultrasonic lithotripter," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. If your urologist also fragments a bladder calculus during the same session, your coding will then depend on the different and separate anatomical location of the stones. Therefore, in the sample scenario, you can separately report those procedures. "We are dealing with two separate portions or parts of the urinary tract -- a ureteral stone and a bladder stone," Ferragamo explains.

Here's why: According to the Correct Coding Initiative (CCI), codes 52317 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small [less than 2.5 cm]) and 52318 (...complicated or large [over 2.5 cm]) are bundled with 52353. Because both bundles have a modifier indicator of "1," however, you can break the bundle using a modifier because the stones are in different anatomical locations. You'll use modifier 59 (Distinct procedural service) to break the bundle.

Sequence the Codes Based on RVUs

Myth: You should always report the ureteroscopic fragmentation first using 52353.

Reality: Once you determine that you can separately report the ureteroscopic lithotripsy of a ureteral stone and cystoscopic lithotripsy of a bladder stone, you need to determine which code to report first on your claim, based on the relative value units (RVUs) assigned to the codes you're reporting.

"The correct sequence of billing for these procedures depends upon the size of the bladder stone," Ferragamo explains.

How it works: If the bladder stone is larger than 2.5 centimeters -- or there were multiple stones requiring fragmentation -- you should report 52318 first for the cystoscopy and the lithotripsy of the bladder stone(s), and then 52353 second for the fragmentation of the ureteral stone. You'll append modifier 59 to 52318 to break the CCI bundle. "This is an unusual circumstance where the bundled second column code pays more and has higher relative value units (RVUs) than the bundling first column code (52353)," Ferragamo says. So in this case you would use 52318 first.

Alternative: If you are dealing with a small, single bladder stone -- less than 2.5 centimeters -- the sequence reverses. In this case, 52353 has higher RVUs than 52317, so you would report 52353 as the primary procedure code and 52317 as the secondary procedure code. Append modifier 59 to 52317 to break the bundle. Different Diagnoses Will Support Separate Billing

Myth: A stone is a stone, so your diagnosis code will be the same for both procedures.

Reality: In this case, the stones are in separate areas within the urinary, which means you will assign separate diagnosis codes. For the ureteral stone, use 592.1 (Calculus of ureter). For the bladder stone, use 594.1 (Other calculus in bladder).

Urinary stones are caused by mineral buildup (usually calcium oxalate or uric acid) that forms in the kidneys and turns into hard "stones." The anatomical location of the stones narrows down the ICD-9 coding for the procedure, however.

Pointer: You may need to add modifier 51 (Multiple procedures) to the second procedure code if you are reporting the procedures to a payer other than Medicare. Many payers no longer require modifier 51, but some still do. Processing claims electronically allows the payer to recognize when your physician performs multiple procedures and automatically makes the necessary reduction in payment. Check with your payer to see if you need to use modifier 51 when your urologist performs more than one procedure in a session.