Urology Coding Alert

Question: A patient came into our office for a stent removal, and the nurse removed it using the attached string. The physician did not see the patient. Can we still bill for this using 52310?


Oregon Subscriber

Answer: No, you should not report 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) for this service. This code specifies that the patient undergoes a cystourethroscopy. Since the urologist didn't perform a cystourethroscopy, you should not report 52310.

If the patient is in a postoperative global period, you should consider the stent removal by the nurse as part of the regular postoperative care associated with the original surgery. If there was no global period associated with the original procedure, you should report a nurse visit.

Report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...) for this service if only the nurse sees the patient. If the urologist also sees the patient, you should  report the appropriate established patient E/M code (99212-99215) rather than just the nurse visit code (99211).