Urology Coding Alert

Stone-removal often includes a retrograde pyelogram (74420) to locate the stone, the removal itself (52352 or 52320) and the insertion of a stent (52332) to keep the ureter open after the procedure is complete. Frequently, urologists use C-arm fluoroscopy to visualize the stone during the procedure. Correct modifier use in this situation is crucial to receive proper payment.

Choose the Correct Procedure Code Combination

If the stone is removed ureteroscopically under direct vision, use 52352 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]). If you remove the stone under fluoroscopic control only, without ureteroscopy, report 52320 (cystourethyroscopy [including ureteral catheterization]; with removal of ureteral calculus). The latter procedure is most often performed for a small distal ureteral stone.

You may also choose the stone extraction code based on the stones location, says Cynthia Jackson, RRA, CPC, coding specialist for Emory University Urology Group in Atlanta. With 52352, you perform cystoscopy along with ureterosocpy and/or pyelography, she explains. With 52320, the stone is almost in the bladder and you dont have to go into the ureter.

Both 52352 and 52320 include the stone extraction. The urologist places the stone grasper through the endoscope (a cystourethroscope in the case of 52320, a cystoureteroscope in the case of 52352) and removes the stone.

When performing a diagnostic ureteroscopy looking at but not extracting a stone report 52351 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic).

For viewing the stone on x-ray or fluoroscope, bill 74420 (urography, retrograde, with or without KUB) with modifier -26 (professional component) for the radiological procedure when you perform and act on the initial reading and write a separate radiology report. The catheterization (53670) and instillation (51700) for the retrograde pyelogram are included in the cystoscopy procedure.

Bill 52332 (cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) for the stent insertion.

Using Modifiers With 52332

You must append a modifier to 52332 to be paid for the stent insertion. For Medicare, append modifier -59 (distinct procedural service) to show that you are inserting the stent for a different reason (keeping the ureter open postsurgery) than that prompting the cystourethroscopy (to visualize the stone).

For a private payer, do not append modifier -59; rather, append modifier -51 (multiple procedures), says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding and compliance consultancy based in Denver. Some private payers adopt Medicare bundling edits, however. If the payer denies reimbursement for 52332 with modifier -51 [...]