Urology Coding Alert

Question: The physician palpated the patient's flaccid penis, and found a hard area in the tip. The doctor determined the patient had a urethral stone but could not get it to pass, so he administered morphine and removed it with a pair of forceps. How should I report this?
      
South Dakota Subscriber

Answer: You may be best off rolling the work, the risk associated with the procedure, and the intravenous morphine administration (for example, parenteral controlled substances) into an evaluation and management code.

Code 52310 describes "Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple." The physician did not perform the cystourethroscopy portion of the code, however, which some payers may consider a large part of the service.

Option 1: Append modifier -52 (Reduced services) -- but because insurers could view the cystoscopy as a large and significant part of the service, your physician may not have adequately met the requirements for the code, period.

Option 2: You could consider reporting a urethral dilation code if the physician documented that he used forceps to dilate the urethra. Keep in mind, if you decide to go this route, that these codes require that the physician dilate a stricture.

-- Answers to You Be the Coder and Reader Questions contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 22-urologist practice in Indianapolis.