Urology Coding Alert

Question: I'm trying to find the code for a percutaneous cystolithotomy. I can only find the code for an open cystolithotomy. Per the op note, "The patient has a neobladder, and a physician placed two percutaneous tubes via interventional radiological techniques. The urologist used a NephroMax balloon dilator to enlarge the tract of one of the percutaneous access sites without difficulty. The tract was easily dilated and the sheath was then advanced over the balloon. Access was then easily maintained in the neobladder. A combination of ultrasonic lithotripter and the lithoclast was used to break up the stones. Stones were removed with a combination of suction through the ultrasonic probe and a stone grasping forceps." What codes should I be using?

Answer: If the urologist performed the neobladder access, choose code 53899 (Unlisted procedure, urinary system) for the percutaneous access to the neobladder. There is no CPT code that comes close to your access procedure, so you should use this unlisted code.

You will need a detailed operative report and cover letter with a full explanation in layman's terms of what your urologist did and why, with specific reference to the percutaneous access to the neobladder. Your carrier will request this for payment determination. Use diagnosis 936 (Foreign body in intestine and colon) for this procedure.

Next: Report 52318-52 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large [over 2.5 cm]) for the lithotripsy of the stone in the "substitute bladder" (neobladder). Modifier 52 (Reduced services) indicates that your urologist performed this procedure without the cystoscopic examination. Use diagnosis 594.1 (Other calculus in bladder) for this procedure and CPT code.