Urology Coding Alert

Keep these 5 factors in mind as you prepare your claims.

Urologists place ureteral stents to hold the patient’s ureter open so urine can drain properly. Although some stents are left in place for as long as two or three months, in many cases it’s left in place for only a few days after a procedure. You have several factors to consider from a coding perspective when it’s time to report stent removal or removal with replacement. Watch these five factors to keep your claims on track.

Factor 1: Understand Your Code Options

Coding for ureteral stent removal and replacement saw a major shift in 2006, when CPT^® added six new codes for the procedure. Before that point, your only choice was to report the stent change with the existing endoscopic approach codes.

Current versions of the stent placement codes are as follows:

• 50382 – Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation
• 50384 – Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation
• 50385 – Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation
• 50386 – Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation.

Take note: These codes saw another change in 2017, with the removal of moderate (conscious) sedation from the procedure. Using moderate sedation is no longer considered an integral part of the stent removal and/or replacement, so you can report the sedation separately if the urologist chooses to use this sedation.

Also important: If the urologist is unable to place a stent, he might perform a nephrostomy instead, says Michael A. Ferragamo, MD, FACS, assistant clinical professor of urology with the State University of New York, University Hospital and Medical School at Stony Brook. During this procedure, the urologist places a tube percutaneously through the skin of the flank into the kidney and connects the tube to an external drainage bag.

When the urologist removes and replaces a nephroureteral catheter, report code 50387 (Removal and replacement of externally accessible nephroureteral catheter [e.g., external/internal stent] requiring fluoroscopic guidance, including radiological supervision and interpretation).

If the urologist does not use fluoroscopic guidance when removing a nephrostomy tube or an externally accessible nephroureteral catheter and does not replace the stent, you should report the appropriate E/M code instead of 50387.

The 2017 CPT^® manual tells us that for change of a ureterostomy tube or externally accessible ureteral stent via an ileal conduit, you should report 50688 for unilateral or bilateral stents.

Factor 2: Pay Attention to the Approach

Don’t miss that codes 50382-50389 are not just differentiated by whether the procedure included a stent removal with or without a stent replacement. Another key to choosing the correct code is based on the surgeon’s approach whether that be via a percutaneous approach, through the skin of the flank (i.e., back) or a transurethral approach without performing an endoscopic view of the bladder. With the transurethral approach, Ferragamo says, the stent is removed blindly through the intact urethra using a grasper under fluoroscopic or other radiological controls.

Factor 3: Watch for ‘Indwelling’ or ‘Externally Accessible’

There are two types of ureteral stents: indwelling and externally accessible. A portion of an externally accessible stent is outside the body and easily removed with little manipulation or invasiveness.

As with many procedures, reimbursement will vary depending on whether the urologist performs the stent removal/replacement in-office or in a facility. From a reimbursement perspective, you will also earn a higher payment with removal/replacement of indwelling stents when compared with removal/replacement of externally accessible stents.

Here’s a quick look at the total RVUs assigned to each procedure for non-facility and facility settings.

Final note: Never code based on RVUs or expected reimbursement. Always code procedures based on the level of documentation your physician provides.

The most frequently billed CPT® code for a double J stent insertion/removal is 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or doubled J type]).