Urology Coding Alert

Hint:  50590 applies to a stone in the kidney or ureter

Extracorporeal shockwave lithotripsy, or ESWL, is a common procedure that urologists perform, but many nuances can make coding the procedure less than common.

CPT Code 50590 (Lithotripsy, extracorporeal shock wave) seems fairly self- explanatory. However, where the stone is located, how many stones there are, and whether the physician also places a stent can make coding a challenge. Take a look at our expert's answers to your top ESWL questions and solidify your coding.

Limit How Often You Report CPT 50590

Question: Our urologist performed ESWL on multiple stones in the patient's kidney during the same operative session. Should I report 50590 for each stone?

Answer: The simple answer is no. You cannot report 50590 multiple times for one session based on the number of stones the urologist must fragment. The same CPT code applies even if the stones are in multiple locations within the same kidney or corresponding ureter.

Example: A patient has a stone in his left kidney, so the urologist performs an ESWL. During the procedure, the physician discovers another stone in the left ureter and proceeds to fragment that stone as well.

While you may be tempted to report 50590 twice because there were two stones, each in a different location, you should only report it once. The relative value units (RVUs) for 50590 are assigned to accommodate instances when the urologist treats single or multiple stones in the same kidney and/or ureter. Remember that when you're  fragmenting stones with ESWL, the kidney and corresponding ureter are considered the upper urinary tract and the bladder the lower urinary tract.

Helpful hint: If a patient has stones in both kidneys, the urologist will usually perform two separate procedures at different times. The physician should write in the op note of the first ESWL that he plans to perform a second procedure on the other side in a few weeks. This indicates to your payers that the urologist planned, or staged, the two operative sessions.

You'll therefore report the first procedure with 50590 and then report the second procedure with 50590, appending modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to indicate the staging, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook. Code 50590 has a 90-day global period.

Remember: You should also use modifiers LT (Left side) and RT (Right side) to indicate which side the urologist operated on during which session. In other words, if he performs the ESWL on the right side first, you'd report 50590-RT and then 50590-LT-58 for the second procedure.

Alternative: If the urologist does decide to treat the bilateral stones whether in kidneys, ureters, or both in one operative session, report 50590 and append modifier 50 (Bilateral procedure).

Account for a Ureteroscope

Question: My urologist performed an ESWL and then used a ureteroscope in order to perform a laser lithotripsy of a mid-ureteral stone. Should I still report just 50590?

Answer: Code 50590 is not the only code you should report. You'll also need to report 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]) for the ureteroscopic mid-ureteral stone fragmentation, Ferragamo says.

Beware: Ensure that you attach modifier 59 (Distinct procedural service) to 50590 in this scenario. The National Correct Coding Initiative bundles the two codes, and you need the modifier to unbundle 50590 from 52353. Although 50590 is the bundled code, sequence 50590-59 as the primary procedure because this code has the higher RVUs and pays more, and report 52353 as the secondary procedure.

Separately Report Stent Insertions

Question: After performing the ESWL, the urologist cystoscopically placed a ureteral stent to prevent any potential urinary obstruction. Is the stent insertion considered part of the ESWL procedure?

Answer: In addition to reporting 50590, you should also report 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) for the placement of the stent. These two codes do not produce a bundling edit, and consequently no modifier is needed.

Modifier requirements: Append modifier 51 (Multiple procedures) to 52332. "As indicated in the NCCI edits, at one time CMS did consider 52332 to be bundled into 50590, but as evidenced by the deletion date, this edit was removed retroactively," says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis. "Some commercial payers tend to follow NCCI edits but neglect to make revisions to remove edits."

In addition: Check with your commercial payers to see if you should use modifier 59. "Be sure this is a true stent and not a temporary catheter removed at the end of the procedure," Hause says.

Identify the Rules for Coding Stone Localization
 
Question: Prior to performing the ESWL, the urologist performed a cystoscopic examination and retrograde pyelogram to localize the stone. Is it appropriate to separately report the localization procedures, or do they fall under the surgical package of the ESWL?

Answer: You should report the cystoscopy and retrograde pyelography separately. First, report 50590 for the ESWL, since this is the more extensive procedure.

Next, report 52005-59 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation or ureteropyelography, exclusive of radiologic service) for the retrograde study to identify if a stone is present and its location. Add modifier 59 to unbundle 52005 from the ESWL.

"Because this is an independent procedure and is not performed routinely when a urologist performs an ESWL, it is separately reportable," Ferragamo says. "Note, if the performance of the cystoscopic examination and retrograde pyelogram leads to a decision to perform the ESWL, then the procedure becomes a billable service.

Bonus: If your urologist also reads the x-rays and documented the radiological findings in his report, you should report 74420-26 (Urography, retrograde, with or without KUB; professional component) as well.