Urology Coding Alert

Question: My doctor performed a cystourethroscopy, with lithotripsy including insertion of indwelling ureteral stent on the right ureter. Additionally, he documented “a 1.9 french basket was introduced through the ureteroscope and the stone fragments were removed.” This is exactly as it is written in the dictated operative report. He has submitted codes 52356 and 52352-59. I need to clarify if these two codes can be billed together with a 59 modifier. The CPT^® code book states I cannot report 52356 with 52332 or 52353 “when performed together on the same side,” but there is no mention of 52352. Any help you could provide would be greatly appreciated.

California Subscriber

Answer: The work associated with 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)) includes the work of 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)) when performed on the same structure. Therefore, in that scenario, you should report only 52356.

If your urologist had performed the lithotripsy and stone removal on separate sites, you would be able to submit both codes and append modifier 59 (Distinct procedural service) or XS (Separate structure, a service that is distinct because it was performed on a separate organ/structure) to 52352. You may also differentiate the different sides by adding modifiers LT (Left side) and RT (Right side) to the appropriate CPT^® code.

Tip: The National Correct Coding Initiative (NCCI) edits reinforce that you should count the stone removal work as part of the lithotripsy work by bundling 52352 with 52356. While there is a modifier indicator of “1,” on this bundle — which means you can override the edit, if appropriate, using a modifier, such as modifier 59 or modifiers XE (Separate encounter…), XS (Separate structure…), XP (Separate practitioner…), or XU (Unusual non-overlapping service…) — you shouldn’t in this case. You should never use modifier 59 and other NCCI-associated modifiers to bypass an NCCI edit unless you meet the proper criteria for using the modifier. The documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that you use. Because your urologist performed both procedures in the right ureter, you can’t override the NCCI bundle.