Urology Coding Alert

Question: The patient had a stent put in place during a prior procedure a week earlier. The procedure notes read: “On examination in lithotomy position, chaperoned , the distal end of the stent was seen just inside the urethral meatus. Therefore, I grasped it with a grasping forceps placed through a cystoscope and then gently eased it back into the bladder and continued to guide the distal end of the stent up the ureter into proper position with the distal stent coil again visible within the bladder.”

We have never seen this, and I am not sure how to code for it. I cannot see using 52310 because the surgeon didn’t remove anything. Or would we code this as 52000 since we entered the bladder when we push the stent back into the bladder?

Pennsylvania Subscriber

Answer: Based on your description, this seems like a return trip to OR due to a complication of stent migration. Code 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) is not appropriate to use; neither is 52000 (Cystourethroscopy [separate procedure]) because the physician performed stent manipulation rather than examination.

Your best option is the “unlisted” code 53899 (Unlisted procedure, urinary system) benchmarked to 52332 (Cystourethroscopy with insertion of indwelling ureteral stent…).

Explanation: As per CMS, when treatment of complications requires a return trip to the operating room, physicians should bill the CPT^® code that describes the procedure performed during the return trip and append modifier 78. If no such code exists, the physician should use the unspecified procedure code as in the above case.  An unspecified procedure code does not accept modifiers, and therefore, a modifier should never be appended to any unspecified CPT^® code.