Urology Coding Alert

Question: Our urologist used grasping forceps to retrieve several stones that were embedded in the patient's prostatic urethra. I'm confused by the descriptors for codes 52310 and 52315. Which one should I use to report this procedure?

Michigan Subscriber

Answer: The encounter you describe represents a complicated procedure – urethral calculi that are embedded into the prostatic urethra making their removal much more difficult as the urologist must "dig" the calculi out of the prostate gland. When reporting the complicated removal of the prostatic urethral stones, you should submit 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; complicated).

You would use 52310 (... simple) for a simple removal. For either type of removal, assign diagnosis code N42.0 (Calculus of prostate) for the prostatic calculi/stones.