Urology Coding Alert

Question: My urologist performed a looposcopy and with a grasping forceps removed the ureteral stent that was in the ileal conduit. How should I report this procedure?

Tennessee Subscriber

Answer: You have two coding options for this scenario.

Option 1: Report 44380 (Ileoscopy, through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the looposcopy. Append modifier 22 (Increased procedural services) to 44380 to indicate the extra work of removing the stent. Attach 963 (Foreign body in intestine) as the diagnosis code.

Option 2: Report 52315 (Cystourethroscopy, with removal foreign body, calculus, or ureteral stent from urethra or bladder; complicated). Since the ileal conduit acts as a substitute bladder, you can use 52315. Add modifier 52 (Reduced services) to 52315 to indicate that your urologist did not perform the cystoscopic examination, but did perform a looposcopy. Use 939.0 (Foreign body of urethra and/or bladder) for the diagnosis code.

Then, also report 44380 for the looposcopy, with 963 for the diagnosis.