Urology Coding Alert

Question: A patient of ours underwent an extracorporeal shockwave lithotripsy (ESWL) procedure, typically coded as 50590. During this procedure, the urologist addressed two kidney stones located in different parts of the right kidney. One of these treatments was a follow-up to a previous ESWL procedure conducted less than 90 days prior, while the other stone was a new discovery and was treated for the first time. What would be the most precise way to bill this to ensure accurate reimbursement?

Colorado Subscriber

Answer: When billing 50590 (Lithotripsy, extracorporeal shock wave), you should only bill one code for the treatment of multiple stones on the same side, regardless of stone location in the kidney or ureter. In this case since an initial ESWL was performed less than 90 days ago (ESWL has a 90-day global period) and was documented in the original operative report that an additional ESWL might be necessary, add modifier 58 (Staged or related procedure...) to the second ESWL code as 50590-58 to ensure payment, If the treatment of the initial stone by a second ESWL during the postoperative period is necessary and not previously documented, append the 78 modifier (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) as 50590-78.

“The reporting of the appropriate modifier will ensure proper payment of the procedure whether the procedure was planned during the initial encounter or whether a follow-up procedure was necessary. Documentation is vitally important to be able to assign the correct modifier,” says Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coder and consultant in Glen Burnie, Maryland.

In the scenario where stones are present on both sides, you can use modifiers RT (Right side), LT (Left side), or 50 (Bilateral procedure) as appropriate, based on the payer’s preference for claim submission. However, in the case scenario you mentioned, where two stones were treated in different locations within the right kidney, you would not use these modifiers as both stones were on the same side (right kidney). For the diagnosis, you would include N20.0 (Calculus of kidney) to indicate the presence of kidney stones. If there were any complications or additional conditions related to the kidney stones, such as hydronephrosis or renal colic, you would need to include additional codes to accurately represent the patient’s condition.

If your doctor feels he put in more time and work than usual in fragmenting the multiple kidney stones, consider appending modifier 22 (Increased procedural services) with strong supporting documentation of the extra work and time spent.