Urology Coding Alert

Question: During a planned ureteroscopy, stone extraction, and possible laser lithotripsy procedure, my urologist found a ureteral stricture at the ureterovesical junction. After three unsuccessful attempts to pass glidewires and stents, he also attempted to dilate the stricture using two methods, both unsuccessful. He was, however, able to inject contrast that showed ureteral dilation all the way up to the renal pelvis. The duration of these services was a little over half an hour before the patient was reversed from anesthesia. Should I code the incomplete ureteroscopy as a discontinued or reduced service?

UCA Subscriber

Answer: Determining whether a procedure should be considered discontinued can be tricky, especially when you have modifier -52 (Reduced services) and modifier -53 (Discontinued procedure) available as options for an incomplete services.

But when using these modifiers, some part or portion of the procedure or procedures must have been performed. Modifiers -52 and -53 can be applied only to CPT codes that have been incompletely accomplished some part of the procedure must have been done before being discontinued or reduced.

In the above example, the only part of the planned or attempted procedures that was actually performed was the cystoscopy and retrograde pyelogram a distinct part of the planned procedure. Because there is a CPT code that reflects just these procedures, you should code only: