Urology Coding Alert

Question: How should I code for a stone extraction from the Koch pouch?

Alabama Subscriber

Answer: The first code you'll report will depend on the number of stones the urologist removed from the Koch pouch. For a single stone you'll use 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple). For multiple stones or stones formed on a foreign body (such as mucus-induced stones), use 52315 ( ... complicated).

Explanation: You should report these codes because in clinical terms, the pouch is a substitute for the urinary bladder.

Append modifier 52 (Reduced services) to either code to show that your urologist did not perform a cystoscopy. You'll attach diagnosis code 594.1 (Other calculus in bladder) to the stone removal code.

Don't miss: You should also report 44385 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the endoscopy of the Koch pouch (in place of the cystoscopy).

Append modifier 51 (Multiple procedures) if your payer requires this modifier for separate procedures. (See the reader question on the right for more on modifier 51.) Use diagnosis code 936 (Foreign body in intestine and colon) with this procedure code.