Urology Coding Alert

Question: My urologist inserted a ureteral double J stent and then performed an ESWL for a large renal pelvic calculus. Because this patient has a long history of chronic urinary tract infections and nephrolithiasis, the proximal stent coil within the renal pelvis quickly became encrusted with stone debris, and the urologist could not remove the stent cystoscopically in the office. Therefore, the urologist performed a cystoscopy in the operating room under anesthesia, performed a ureteroscopy and fragmentation of the encrusted coil in the renal pelvis using a Holmium laser, and then was able to remove the stent and all remaining stone pieces from the bladder. Can you help me with the coding of this case?


Massachusetts Subscriber

Answer: First, report 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]) for the ureteroscopy and fragmentation of the encrustations. Append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to 52353 to ensure payment of the procedure because the urologist had to perform it during the 90-day global of the extracorporeal shock wave lithotripsy (ESWL).

Next, you should use 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; complicated) for the complicated removal of the stent in the operating room. The removal is considered complicated because the stent was encrusted with stone debris. Again, you should append modifier 58 to this code.

Tip: If the urologist had to perform extra work and spend extra time to completely fragment the stone attached to a foreign body (the J stent coil), consider appending modifier 22 (Unusual procedural services) to indicate this extra time and effort.

Alternative: If the urologist fragmented calculus material attached to the stent's distal end within the bladder, report 52318-58 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large [over 2.5 cm]). Then, report 52315-58-59 for the complicated stent removal. Add modifier 59 (Distinct procedural service) to 52315 because the National Correct Coding Initiative bundles 52315 into 52318; however, 52315 represents a distinct separate procedure performed at the same time as 52318.