Urology Coding Alert

Question: A Medicare patient had ESWL last month. The physician was not successful in breaking up the stone, and the patient is now having a cysto, retrograde pyelogram, ureteroscopy with stone basket and double-J stent. This falls in the 90-day postoperative period. Can I bill with modifier -58 and will Medicare pay? Is there a more appropriate modifier?

North Carolina Subscriber

Answer: Modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) is the correct modifier to use, and you should be reimbursed at 100 percent of the Medicare Physician Fee Schedule allotment for the subsequent procedure just be sure you indicate to the payer that modifier -58 is being used to indicate that the second procedure was more extensive than the first.

When a procedure is performed in a global period for the same diagnosis as was linked to the initial procedure, the second procedure either had to have been planned prospectively at the time of the initial procedure or must have been more extensive than the original procedure to be separately billable.

In the scenario you describe, the second procedure was more extensive than the first and will be paid in full by adding modifier -58 to the second procedure.

You should report codes 52352-58 (Cystourethro-scopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]) for removal of the stone and 52332-58-59 for the double-J stent insertion. By appending modifier -59 (Distinct procedural service) to 52332, you will unbundle the stent insertion from 52352 and will receive separate reimbursement.

Check to see whether the physician also documented a reading of the retrograde pyelogram during the second procedure. If so, you should also use 74420-26(Urography, retrograde, with or without KUB; Professional component), appending modifier -26 to indicate that the urologist only read the pyelogram and did not own the equipment (this procedure is typically performed in the facility setting).