Urology Coding Alert
Capture Return-to-OR Pay with 78
Question: A patient had a ureteral reimplant early in the afternoon. Later that evening, the patient was experiencing severe flank pain. The surgeon ordered an x-ray which showed the ureteral stent was coiled in the ureter instead of the kidney. The surgeon took the patient back to the OR (within the same calendar date as the ureteral reimplant). He did a cysto and repositioned the stent. Can I bill for the second procedure in the same day?
Minnesota Subscriber
Answer: Yes, you can report and expect to be paid for the second procedure. You’ll need to use modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to do so.
The code you report will depend upon the actual surgery your urologist performed. For example, you might report 52000 (Cystourethroscopy [separate procedure]) or 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic).
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