Urology Coding Alert

Question: The urologist scheduled a procedure for a patient who had multiple stones. The stone in the ureter was manipulated into the renal pelvis, then he performed flexible ureteroscopy with stone manipulation of mid and lower pole stones into the upper pole. Next, the urologist completed laser lithotripsy of stones in the upper pole. However, a stone remained in the lower pole which was laser fragmented. He placed a stent with string attached. I’m getting confused trying to decide how to report everything, considering that cystoureteroscopy is covered in each. What’s your recommendation?

West Virginia Subscriber

Answer: Recently this clinical scenario has been addressed, and Medicare and many private carriers will pay only once for the treatment of several stones within the one kidney. Also remember that the manipulation of ureteral stones into the kidney has been included in the subsequent stone treatments. So in your case scenario, report the primary treatment (fragmentation) of the stones and the insertion of a JJ stent with code 52356 (Cystourethroscopy, with ureteroscopy and pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [e.g., Gibbons or double –J type]).

However, if the fragmentation of this many stones prolonged the operative procedure significantly, one may add modifier 22 (Increased procedural services) to seek additional payment. You should submit 52356-22 to indicate the extra time required to completely fragment all the stones and completely document in detail each procedure performed, stone locations, and the extra time needed to complete the fragmentation.