Urology Coding Alert

Question: What are the correct CPT^® and diagnosis codes for aspiration of a perinephric hematoma following an extracorporeal shock lithotripsy, ESWL, for a renal pelvic stone?

New Mexico Subscriber

Answer: The correct procedure code is 49405 (Image-guided fluid collection drainage by catheter [e.g., abscess, hematoma, seroma, lymphocele, cyst]; visceral [kidney, liver, spleen, lung/mediastinum]). If performed the procedure is performed within the 90-day global period following the ESWL, add modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional Following Initial Procedure for a Related procedure during the postoperative period) to the 49405 to indicate the treatment of a complication and ensure its payment within a global period.

Notice that CPT^® 2017 revised the descriptor so that it no longer includes moderate/conscious sedation as an inherent part of the procedure. You can now include moderate sedation as a separate item on the claim, when appropriate. Choose the correct code from 99151-99157 (Moderate sedation services ...), based on three factors: the patient's age, the amount of time involved, and whether the same provider provides sedation and performs the procedure.

Include diagnosis N99.840 (Postprocedural hematoma of a genitourinary system organ or structure following a genitourinary system procedure) on the claim.