Urology Coding Alert

Pinpoint the location for your first coding clue.

Coding for treatment of multiple urinary system stones can be tricky if you don’t pay attention to certain details. Here’s what you need to know regarding anatomic structures and where procedures were performed in order to narrow your options to the correct choice.

1. Pay Attention to Structures

Just as the old realty agent slogan claims, location is everything. Coding for stone destruction or removal is based largely on where the stones are located.

“They need to be in different structures,” says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri’s Department of Surgery in Columbia.

You should not bill separately for treatment of multiple stones in a single kidney or a single ureter. However, you may bill separately for stones in separate anatomical structures.

“Typically, our multiple stone scenario means our surgeons are treating ureteral stones and kidney stones at the same operative session,” says Leah Gross, CPC, CUC, coding lead at Metro Urology in Woodbury, Mn. “We never report multiple codes for the same stone, or for the same location. I’ve expressed to our surgeons that it is imperative that the documentation speaks to the level of effort and shows clear separation of the multiple procedures.”

Example: The urologist performs ureteroscopic fragmentation of a renal pelvic stone and fragmentation of an ipsilateral proximal ureteral stone. Because these are two separate stones in separate structures of the urinary tract, you can report each service. Submit 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]) with diagnosis N20.0 (Calculus of kidney) and 52353 with modifier XS (Separate structure) for Medicare or modifier 59 (Distinct procedural service) for private and commercial carriers adding diagnosis N20.1 (Calculus of ureter).

The same procedure codes (52353) are allowed because the stones were in separate structures. You are dealing with a renal pelvic stone and a ureteral stone, and although anatomically the renal pelvis and ureter are continuous structures, for coding purposes they are considered separate anatomical structures.

Caveat: Some carriers, including Medicare, may not reimburse for the same CPT^® code twice when performed in separate structures on the same side even using the correct modifier.

In these circumstances, appeal any denials because you should be paid based on the above.

2. Don’t ‘Double Dip’ Procedures

You cannot report the same procedure twice if the surgeon performs it on two stones in the same structure.

Example: The surgeon completes fragmentation of a calyceal stone and fragmentation of an ipsilateral renal pelvic stone with placement of a JJ stent.  Because the stones are in the same organ/structure, bill only 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) one time. 

However, when stones are in the renal pelvis and a calyx of the same kidney, and each is treated by different techniques (such as fragmentation for the renal pelvis stone and extraction of the calyeal stone), some payers will reimburse for both procedures especially if well documented in the operative report. For this clinical scenario, submit 52353 for the fragmentation of the renal pelvic stone and 52352-XS for the extraction of the calyceal stone

By the same token, do not charge for multiple procedures on one stone, such as manipulation and then fragmentation. Determine which of the procedures mostly accomplishes the intended surgery, and bill only for it. 

3. Watch the Technique and Use the Appropriate Modifier

Using different techniques to treat stones may justify the use of a different modifier.

Example 1: The surgeon performs ESWL for a renal pelvic stone and ureteroscopic  fragmentation of an ipsilateral ureteral stone. Code 50590 (Lithotripsy, extracorporeal shock wave) with diagnosis N20.0 and 52353 with diagnosis N20.1. In this scenario, append modifier XU (Unusual non-overlapping service) to 52353. These qualify as unusual, non-overlapping services since the physician used different equipment and different operative techniques.

Example 2: The urologist completes ureteroscopic fragmentation of a left renal pelvic stone and ureteroscopic extraction of an ipsilateral distal ureteral stone. Bill 52353 with diagnosis N20.0 and 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]) with diagnosis N20.1. Append either modifier 59 (Distinct procedural service) for commercial or private payers or XS for Medicare to 52352. Since the treatment of the two stones uses two different procedures during the same ureteroscopy, code the two procedures using XS on the second stone in a different structure.

Example 3: Sometimes a claim might merit modifier 22 (Increased procedural services) when separate CPT^® codes are not appropriate, Gross says. “When the documentation supports significant additional time or anatomical difficulty, we utilize the 22 modifier,” she says. Examples of documentation that might support modifier 22 include:

• Statements of time, such as “50 percent additional laser time” or “procedure took twice the normal amount of time to perform.” Notes with these details are preferred over statements such as “the case took an additional 20 minutes to complete” because they give more direct descriptions of how much additional work took place.
• Anatomical details, such as “significant tortuosity of the ureter which had to be navigated with extreme caution” or “I painstakingly searched each calyx and basketed over 100 fragments.” “If the issue is anatomical r due to the amount of stone, the more descriptive the surgeon can get, the better,” Gross says.

Top advice: “Documentation needs to support the billing of separately identifiable procedures,” Boone says. “If they are treating the same stone with two different procedures these are not to be unbundled. I bill by Medicare rules and the AMA. Other coders may need to refer to the carrier rules for their particular state.”

“Any way they can spell out the difference in documentation is a huge help,” Gross agrees. “Even dictating separate paragraphs for each portion can help paint the picture.”

“Though it may seem trivial to you and me, the reviewer at the insurance company may not understand urology,” Gross adds. “But the reviewer should have the ability to see well-documented separate locations, procedures, actions, tools, and passes of scopes that equate to additional reimbursement.”

Remember you may code and bill for the simultaneous treatment of stones in the kidney, ureter, and bladder during one sitting.

Plus: Remember that Medicare rules for stone coding may differ from the rules of private and commercial insurers. Therefore, be sure to check with the various insurance carriers when unusual clinical stone scenarios arise.