Urology Coding Alert

Question: After informed consent was obtained, the patient was brought back to operating room and underwent general IV sedation. She was placed in the low lithotomy position. The urologist prepped the patient, and a time-out was performed. The urologist then inserted a 22-French rigid cystoscope into the urethra and advanced it to the bladder. The urologist identified the remaining ureteral stent. The encrustations from the ureteral stent had now fallen off and were in the bladder. The urologist removed the ureteral stent and discarded it. The encrustations and stones required graspers to break them up and remove them. The urologist removed all stones and calcifications from the bladder. The bladder was emptied. Patient was returned to supine position and taken to the recovery room stable condition. Which codes should I report?

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Answer: You should report the following codes:

• 52318 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm)) for the crushing and removal of several stones
• 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple) for the removal of the single stent

Don’t miss: You should append modifier XS (Separate structure) to code 52310.