Urology Coding Alert

Question: Does the code combination 52356 with modifier 50 include placement of stents on both sides? Or do I need to report the code twice with different modifiers?

North Carolina Subscriber

Answer: The descriptor for code 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)) represents a single side. When you report 52356 for one side, such as the left, you may append modifier LT (Left side), which includes insertion of the stent on the left side.

When the same procedure is also completed bilaterally during the same encounter, you can simply report 52356 with modifier 50 (Bilateral procedure). This indicates that the urologist performed the same procedure on both sides, including stent placement. There is no need to also include 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)) for the stent itself.