Urology Coding Alert

Although stents and ureteral catheters have a lot in common, differences in how urologists use them mean reporting different codes for their placement and removal.

In urological circles, a stent represents a special ureteral catheter, such as a double-J or Gibbons stent, that is intended to be left indwelling for a period of time, usually to bypass an obstructive ureteral process such as stones, a tumor or stricture. The stent is constructed to remain with one end in the renal pelvis and the other end in the bladder. After a specific period of time, the stent is replaced (exchanged) or removed cystoscopically. You should report CPT 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) for the placement of the stent. For its separate removal, use CPT 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple). However, when you are billing for stent exchange, 52310 can never be billed at the same time as 52332 because it is bundled. Therefore, bill only 52332.

A ureteral catheter is used most often to inject contrast material into the collecting system of the kidney and ureter. This catheter is temporary and not intended to be used for long-term drainage. This type of catheter is also placed in the ureter for protection during a procedure within or outside the ureter. At the conclusion of the procedure, the catheter, unlike a stent, is removed. You should use 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) for the catheterization, which includes insertion and removal, says Jan Brunetti, CPC, billing coordinator for Urology Associates of Newport, R.I.

A typical stent scenario involves a patient who presents with left renal colic (788.0, Symptoms involving urinary system; renal colic), sepsis (038.40, Septicemia due to other gram-negative organisms; gram-negative organism, unspecified) and an obstructing left ureteral stone (592.1, Calculus of ureter). The urologist performs a cystoscopy and J stent placement to bypass the obstructing stone. For this procedure, you should report 52332.

Similarly, a patient has right hydroureteronephrosis (591, Hydronephrosis) secondary to an invading cervical carcinoma (180.0, Malignant neoplasm of cervix uteri; endocervix). The patient complains of right flank pain (788.0, Renal colic). The physician places a double-J stent to bypass the obstruction and relieve the pain and hydronephrosis. In this case, you should code 52332.

In another example, following the ureteroscopic extraction of a lower ureteral stone (592.1, Calculus of ureter), the urologist prophylactically places a double-J stent to avoid obstruction secondary to ureteral edema. You should report 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]) and 52332 appended with modifier -59 (Distinct procedural service) because 52332 is a distinct and independent service.

An intravenous pyelogram (74410, Urography, infusion, drip technique and/or bolus technique) reveals a questionable mass in the left renal pelvis. The urologist performs a cystoscopy and a retrograde pyelogram with contrast agents injected through the ureteral catheter. You should use 52005 and 74420 (Urography, retrograde, with or without KUB) with modifier -26 (Professional component), with radiological reading. Link 793.5 (Nonspecific abnormal findings on radiological and other examination of body structure; genitourinary organs) to 52005 and 74420-26.

Likewise, the urologist is asked to pass bilateral ureteral catheters before major pelvic surgery to help identify the ureters during the procedure. For this procedure, you should report 52005 for Medicare and

52005-LT (Left side) and 52005-RT-50 (Right side; bilateral procedure) for private payers.

Occasionally, both a ureteral catheter and a stent are used during the same session. For example, a urologist passes a ureteral catheter cystoscopically to the renal pelvis to guide the ureteroscope through a tortuous ureter to an upper ureteral stone, which is removed. The physician uses the ureteral catheter for the guidewire and places a double-J stent. In this case, you should report 52352 and 52332-59. You should not code the ureteral catheter placement because 52005 is bundled into codes 52332 and 52352.

In another example, a urologist ureteroscopically laser fragments a left ureteral stone and places a left ureteral double-J stent. Because of a right renal pelvic stone suspicion, the physician inserts a ureteral catheter into the right system and performs a right retrograde pyelogram. Here, you should code 52353 (... with lithotripsy [ureteral catheterization is included]), 52332-59 and 52005-59. Because the urologist placed the ureteral catheter contralat-erally into the right renal pelvis, this is considered a different segment of the urinary tract and is billable with modifier -59 appended to 52005. For private payers, you should bill for the bilateral ureteral catheters as indicated in the example above. In addition, link 793.5 to the procedures.

Similarly, following a ureteral catheter placement for a retrograde pyelogram in an acutely inflamed urinary system, the patient develops severe edema and ureteral obstruction (593.89, Other disorders of kidney and ureter; unspecified disorders of kidney and ureter; other). The next day, the urologist places a ureteral double-J stent to relieve the obstruction and pain. You should report the procedure on day one with 52005, and day two with 52332. Both codes have zero-day global periods, and no modifiers are needed.