Urology Coding Alert

Reader Questions:

Look at Stone Size Before Coding

Question: How should I code a suprapubic cystoscopy with stone removal?

West Virginia Subscriber

Answer: You should report 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; complicated) for the cystoscopy via the cystotomy opening with removal of a large stone or multiple stones.

If the urologist actually performed a simple extraction of a single small stone instead, report 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple).

You should also report 51705 (Change of cystostomy tube; simple) for the cystostomy tube change, if performed. Append modifier 51 (Multiple procedures) to 51705 because your urologist performed more than one procedure during the same operative session.