Urology Coding Alert

Question: The urologist began a percutaneous nephrostomy to look for a stone. He did not find a stone but did discover a retained stent. He was unsuccessful in removing it, so he placed a new stent antegrade. He then removed the nephrostomy tube, repositioned the patient, and successfully performed a cystoscopic stent removal. How should I code this encounter?

Nevada Subscriber

Answer: Your question does not include enough details to give a complete answer, but here are some things to consider as you look at the urologist’s documentation.

If the urologist performed a cystoscopy with stent removal, you can report 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple).

If she placed a new stent through the nephrostomy, you should code 50693 (Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; pre-existing nephrostomy tract).

Look for details in the documentation regarding the type of access. If you have questions, confer with the urologist before submitting the claim.