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Urology Coding Alert

Reader Question:

Stent and Ureteroscopy Codes

Published on Sat Sep 01, 2001

Question: Can we always bill for a ureteral stent when performing ureteroscopic stone procedures?

California Subscriber
 
Answer: This is not a simple question, partly because the ureteroscopy codes were changed for 2001 and partly because billing Medicare for stents has always been controversial, as CPT and Medicare do not always agree. Under CPT rules the stent is separately billable, but Medicare doesn't have to recognize CPT. 
 
The ureteral stent insertion code, 52332 (cystoureth-roscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]), is not bundled under the Correct Coding Initiative (CCI) edits into the ureteroscopic codes. (For more on this, see the May and August 2001 issues of Urology Coding Alert.) Although stents were bundled into ureteroscopy codes last year, CPT 2001 renumbered the ureteroscopy codes, and 52332 is not listed as bundled. In effect, the renumbering constituted a de facto removal of the bundle, and CCI has not replaced it yet, although it has had three versions to do so.
 
The main question is whether to append modifier -59 (distinct procedural service) when billing 52332 with a ureteroscopic procedure. Some coding experts say that if you code according to the "spirit" of CCI you should not bill for a stent in addition to the ureteroscopic procedure unless appending modifier -59. If you code according to the "letter" of CCI, you do not need modifier -59. And in fact, appending modifier -59 to a procedure that is not bundled may only confuse your carrier.
 
Even if CCI did bundle 52332 into ureteroscopy codes, the stent is separately billable when circumstances require it. Again, under CPT rules the stent is separately billable, but Medicare doesn't have to recognize CPT. 
 
CPT says to bill for the insertion of a self-retaining, indwelling stent by appending modifier -51 (multiple procedures) to 52332. Under CCI, you should append modifier -59 to 52332. For Medicare, append modifier -59; for commercial payers, append modifier -51.
 
If you place a ureteral catheter during the ureteroscopic procedure and remove it at the conclusion of the procedure, it is not a billable service. If you place a Gibbons stent or similar permanent stent and leave it in the ureter after the procedure, use 52332. The permanent stent is placed to avoid obstruction from edema or residual calculi. If the urologist thinks a permanent stent is not necessary, he or she will not insert it and should not bill for it.
 
If it is the urologist's standard of practice always to place a stent, the stent becomes an integral part of the procedure and may not be separately billable, so coding experts are hesitant to say you should "always" bill for the ureteral stent, regardless of what modifier you use.
 
If you are billing a commercial payer and using modifier -51, then "always" is justifiable. But when billing Medicare and using modifier -59, you must have a justification for the stent as a "distinct procedural service." If you always insert a stent after the ureteroscopy, it is no longer distinct from the ureteroscopic procedure. Modifier -59 is for a different session or encounter, different procedure, different site, separate incision/ex-cision, separate lesion, or separate injury "not ordinarily encountered or performed on the same day by the same physician."
 
The ultimate justification is that the AMA (see CPT Assistant May 2001) says the stent is separately billable. The AMA even cites the 52330 and 52332 combination.

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