Urology Coding Alert

Question: I performed a ureteroscopy; however, I could only advance the scope to approximately the iliac vessels. Next, I performed a flexible ureteroscopy. I saw the stent in the proximal left ureter. Using a three-prong ureteral grasper, I grasped the stent, but was only able to pull it down to the level of the mid left ureter before the grasper was unable to continue to hold the stent. At this point, I used a combination of a three-prong grasper, a spiral basket, and a Nitinol basket to try to grasp the stent. This took a considerable amount of time. I spent approximately two hours grasping the stent and slowly pulling it down the left ureter. Eventually, I was able to identify this stent in the distal left ureter below the iliac vessels, and redo the ureteroscopy. At this point, it was somewhat easier to grab the stent with the three-prong grasper. However, it still took considerable time to pull the stent down. Eventually, I was able to get the stent into the bladder and remove it. How can I code to capture appropriate reimbursement for all the time this procedure took?

Answer: You should report 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic) for this clinical scenario. Append modifier 22 (Increased procedural services) to indicate that you spent extensive time and effort on this procedure.

When a surgery requires substantially greater additional time or effort that falls outside the range of services described by a particular CPT code and no other CPT code better describes the work involved in the procedure, modifier 22 is your best option.

Get specific: Payers won't accept a modifier 22 claim unless you can provide convincing evidence that the service or procedure was truly "out of the ordinary" and significantly more difficult or time-consuming than usual. Therefore, you should provide a detailed operative report and a comprehensive covering letter of what was done and why and explain the reason for the prolongation of the procedure and therefore, the increased reimbursement requested.