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 alone, resubmit the claim with modifier -59 (i.e., 52332-51-59). Also, remember that many private payers bundle 52332 into the primary operative procedure and will not reimburse the stent insertion. This is contrary to CPT guidelines and should be appealed for payment.

Note: Do not append modifier -51 to these codes if youre billing Medicare, because it will automatically and incorrectly deduct 50 percent of the fee for subsequent procedure codes.

When billing for the pyelogram, append modifier -26 to indicate that the physician does not own the radiology equipment and is billing only for the professional, not the technical, portion of the procedure. In this case, the professional services may include the performance of the procedure and the interpretation of the results.

File the Claim Carefully

When filing the claim, always bill the code with the highest value first. In this case, either the cystourethro-scopy code 52352, with 11.04 relative value units (RVUs) or 52320, with 7.48 RVUs should be listed first. The primary (top-listed) procedure will be paid at 100 percent of the physician fee schedule. Place 52332 on the second line and 74420-26 on the third line. Medicare will pay 50 percent of the full fee for 52332 and a reduced fee for 74420 because of the professional-component modifier.

The claim form would read as follows:

Medicare:
52352 (or 52320)
52332-59
74420-26

Private payer:
52352 (or 52320)
52332-51
74420-26-51

Bill Separately for Fluoroscopic Control

Many urologists perform fluoroscopic guidance during the stone removal. Although a C-arm is a separate piece of equipment, you cannot receive separate payment for it. For fluoroscopic guidance, payers contend that the C-arm is not medically necessary: Youre already visualizing the stone ureteroscopically, so another method of visualization is not necessary.

Note: Fluoroscopic guidance (76000, fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy]) is designated a separate procedure and should not be reported separately from the procedure or service of which it is a part. Separate procedures may only be reported alone if they are carried out independently from the procedure they are normally designated as being included with. If unrelated to the other procedure, it may be reported with modifier -59 appended.

I will never recommend modifier -59 for 76000 unless documentation clearly indicates a need for two separate methods of visualization, Page says although she says she cannot think of a situation in which two methods would be required.

If a payer mistakenly reimburses for 76000-59 with stone removal, you would be expected to return the money, perhaps with penalties, upon postpayment review.

You may bill 74420-26 whether you read the retrograde pyelogram for any of the fluoroscopic images or for the hard-copy images made during the fluoroscopic viewing. Either way, the urologist must prepare a separate written radiology report. In each case, the urologist places the dye in the kidney, but can bill for only the reading because instilling of the dye is done by cystourethroscopy (52005), which is bundled into the stent insertion.