Urology Coding Alert

Question: Can you help me code this scenario:

Preoperative diagnosis: Ileal conduit with a calculus within the conduit

Postoperative diagnosis: The same

PROCEDURE:  Endoscopy of urinary ileal conduit with laser lithotripsy and removal of the calculus.

PROCEDURE IN DETAIL:  The patient being, was verified. Procedure being endoscopy of the conduit with laser lithotripsy was confirmed. Procedure was carried out. Time-out was performed. Intravenous antibiotics were administered. General LMA anesthesia was induced. The patient was placed into a supine position. Sterile field was created by prepping and draping the patient’s right lower quadrant conduit area using Betadine and a percutaneous Epi-Tape was applied. Next, endoscopy of the conduit was performed using a 16-French flexible cystoscope. Inspection of the entire conduit revealed no evidence of tumor recurrence and both ureteral orifices were visualized, laterality course cannot be assessed, 1 was approximately 6- to 8-French in caliber, the other 12 to 14 with previously patent with ureteral peristalsis. There was a relatively large volume of urolithiasis approximately 1 cm at the most proximal end of the conduit. This did appear to be adherent to proximal staple line. Next, holmium laser energy was applied to the stone using settings of 0.2 joules and 10 Hz, and fragmenting the stone off the staple line and then removing the stone fragments with Escape basket and sent for compositional analysis. There was some small residual stone material on the staples which could not be completely addressed due to angulation and motion of the conduit, however, approximately 90% of the stone material had been removed. It was felt that the goals of procedure had been achieved. Final inspection revealed no evidence of perforation. Continued patency ureteral orifices. The conduit was then cannulated with a 16-French red rubber to drain it and a new osteal appliance was applied, make a straight drain. Procedure was then terminated. The patient tolerated the procedure well. There were no immediate peri-procedural complications. The patient was taken to post-anesthesia care unit in stable condition.

Arizona Subscriber

Answer: There are two ways to code this scenario:

Method one: For the first option, first report 44380 (Ileoscopy, through stoma; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) for looposcopy and fragmentation and removal of stone pieces. Attach modifier 22 (Increased procedural services) to indicate the extra work in performing the lithotripsy of the stone in the conduit.

The diagnosis code should be N21.8 (Other lower urinary tract calculus) for the stone in an ileal loop.

Most payers will require you to submit a detailed operative report and a covering letter explaining what your urologist performed in layman’s terms.

Method two: Since the ileal conduit is a substitute bladder, the following coding would also be an acceptable option:

• First, report 52318 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large [over 2.5 cm]) for the fragmentation of the stone complicated by the surrounding mucus in the ileal conduit. Attach modifier 52 (Reduced services) since your urologist did not perform a cystoscopy. Use diagnosis code N21.0 (Bladder calculus). 
• Then, report 44380 for the looposcopy with diagnosis code N21.8, using this code in place of the cystoscopy.