Urology Coding Alert

Question: Is there a way of billing for a stent removal on one side and a ureteroscopy on the opposite side? The Correct Coding Initiative (CCI) bundles two codes -- 52310 and 52353, for example -- and does not allow coders to break the bundle using any modifier. I come across many procedure codes that CCI says I can never report together, but my urologist performs the procedures on different ureters or kidneys. Is there any way to code for these sorts of procedures and get the reimbursement the doctor deserves?

Hawaii Subscriber

Answer: The Correct Coding Initiative (CCI) establishes edits for Medicare, and if the patient's carrier is Medicare, you may have some difficulty collecting payment for the procedures you have asked about. As you state, CCI bundles 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) and 52353 (Cysto-urethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]) with an edit indicator of 0, meaning that you can never bypass this edit with any modifier.

Suggested coding: Despite the CCI bundle, experts suggest that you first report 52353 with modifier LT (Left side) appended for the left-side ureteroscopy and stone fragmentation. You'll attach diagnosis code 592.1 (Ureteral calculus). Then, report 52310 with both modifier 59 (Distinct procedural service) and modifier RT (Right side) for the removal of the right-side ureteral stent. With this code, submit diagnosis code 939.0 (Foreign body in urethra and bladder). Modifier 59 indicates that you intend to break the bundle that CCI puts in place.

Why: Some private carriers that do not follow the CCI may reimburse you for the two procedures when you use modifiers 59 and LT/RT. Medicare as well as some private carriers, however, will strictly follow the CCI. In these cases, the payer will deny one of the codes, usually 52310.

Appeal: Because the urologist should be reimbursed since the procedures involve two different, separate parts of the urinary tract -- the right and left sides -- you should be able to successfully appeal this denial with complete and detailed documentation. You will need to be persistent in your appeals, however.