Urology Coding Alert

Question: I have a patient who had more than one ESWL. The doctor admitted the patient for urinary retention and a cystoscopic examination and urethral dilation, with removal of bladder stones. Can I report the hospital admission with an appropriate modifier?

Florida Subscriber

Answer: You should report more than one extracorporeal shock wave lithotripsy (ESWL) within the global of a previous ESWL using 50590 (Lithotripsy, extracorporeal shock wave). However, you need to append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to indicate a staged procedure.

You can also report the admission, as this was for another problem (urinary retention). You should report 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity). Append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to make the payer aware that the urologist is seeing the patient for a new problem, and therefore the E/M service is not included in the previous procedure's global surgical package.

Additionally: You should report the surgery using 52315 (Cystourethroscopy, with removal ...of calculus... from bladder; complicated) for the removal of multiple bladder stones and urethral dilation. Add modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to the surgical code to indicate a new problem. Your diagnosis would be 594.1 (Other calculus in bladder).