Urology Coding Alert

Question: One of our providers will see a patient within the global period for a related procedure such as an office cystoscopic removal of a double J stent, code 52310. However, this procedure does not require a return to the OR so he sees the patient in the office. I know that Medicare requires you to append modifier 58 when you report a return to the OR, “unless the patient’s condition was so critical there would be insufficient time for transport.” Is the office procedure room considered an OR? Can we append modifier 58 to the procedure code in this situation, or not?

Michigan Subscriber

Answer: According to CMS, Modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the post-operative period) was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure. Modifier 58 indicates that the performance of a procedure or service during the post-operative period was:

• Planned prospectively or at the time of the original procedure;
• More extensive than the original procedure; or
• For therapy following a diagnostic surgical procedure.

Chapter 12, Section 40.4, of the Medicare Claims Processing Manual gives more details about reporting modifier 58. This information does not indicate that the physician must return the patient to the OR before reporting modifier 58. Instead, the physician may provide a postoperative procedure or service, in his office or other inpatient or outpatient setting, as long as the documentation clearly supports the need for the staged procedure.

Bottom line: In the scenario you describe, bill 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) with modifier 58 when your provider cystoscopically removes the stent in the office within the global period of an extracorporeal shock wave lithotripsy, ESWL, or percutaneous nephrostolithotomy, PCNL, both with 90-day globals.