Urology Coding Alert

Question: A patient underwent an ESWL of a left renal pelvic calculus with the documented diagnosis of N20.0. During the 90-day global period a fragment of the renal stone passes into the lower left ureter causing ureteral obstruction. In a return to the operating room, the urologist performs a left uretero­scopic extraction of the ureteral stone and passes a double J stent. How do I code the post-op care? Can I use a modifier to bill an E/M service for the decision for surgery that was made during a post-op office visit? What modifier should I use when I code his second surgery?

Oklahoma Subscriber

Answer: Since the second procedure was for treatment of a complication of the initial ESWL, Medicare will only reimburse for diagnosis or treatment of a complication when a patient is returned to the OR. Therefore, Medicare will not pay for the office visit mentioned. Some private and commercial carriers will pay for the office visit E/M decision for surgery with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) appended in this case scenario. Modifier 24 allows payment for the E/M visit during the global period of the ESWL. A different diagnosis from that of the original procedure is required. Leave N20.0 (Calculus of kidney) on the claim for the original ESWL and report the second procedure with diagnosis N20.1 (Calculus of ureter).

The descriptor for modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) indicates the same initial procedure was performed again at another encounter on the same day. Because your surgeon did not repeat the EWSL, modifier 76 is not the correct modifier choice. 

Coders may also want to consider appending modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) in this type of case. This modifier generally is reserved for additional steps of a procedure that the surgeon knows will require multiple OR sessions. This second procedure does not represent a staged or more invasive procedure, which means modifier 58 would not be correct for your scenario.

When looking at information about modifier 58, don’t miss the associated note: “For treatment of a problem that requires a return to the operating/procedure room… to surgically correct a complication of surgery…see modifier 78.” Therefore, because the urologist performed different procedures – kidney stone and ureteral stone removal – your best option in this scenario should be 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). For the second procedure code 52352-78 and 52332-78.