Urology Coding Alert

Question: The urologist performed a looposcopy and stent removal during the same session. Should I report 44380-22?

Michigan Subscriber

Answer: Although you can use 44380 (Ileoscopy, through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and modifier 22 (Increased procedural services) for this looposcopy and stent removal, there is a better coding scenario.

Best bet: First report 44380 for the looposcopy of the conduit. You'll submit ICD-9 code 936 (Foreign body in intestine) for the diagnosis because the stent is acting as a foreign body.

Next, report 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) for the stent grasping and removal. Append modifier 52 (Reduced services) to indicate that the urologist removed the stent from an artificial or substitute bladder, and he did not perform a cystoscopy, only a looposcopy. You'll use 939.0 (Foreign body in bladder) as the diagnosis for the stent in the substitute urinary bladder.