Urology Coding Alert

Question: Our physician performed a cystoscopy, a right retrograde pyelogram, and a right ureteroscopy with stent placement. In postoperative imaging, the stent was found to be incorrectly positioned. The patient returned to the operating room (OR) the next day for a stent removal. Should I report the stent removal? If so, do I report it with modifier 58 or 78?

Mississippi Subscriber

Answer: First, you’ll want to break the surgeries apart and report the respective CPT^® codes. For the cystoscopy with right retrograde pyelogram and ureteroscopy, you’ll report code 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic) with modifier RT (Right side). You’ll report the right ureteroscopy with stent placement as 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)), also with modifier RT. No bundling edits exist with these codes, so you do not need to report an overriding modifier for the column 2 code.

Next, you’ll address the physician’s removal of the stent in the OR the following day. Since the stent was found to be incorrectly positioned, you would consider this a complication of the original surgery. Therefore, you should consider modifier 78 (Unplanned return to the operating/ procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) for payment. However, since codes 52351 and 52332 have a zero-day global period, no modifier(s) will be necessary for correct billing and payment of a surgical procedure performed the following day. Therefore, you’ll report this service using code 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple).