Urology Coding Alert

Question: A patient was booked for a ureteral stone removal. Per the operative report: “The semi rigid ureteroscope was advanced into the distal portion of the ureter. Then, under direct vision, the wire was passed easily past the stone and up into the kidney. There was an area which appeared to be strictured. After the wire was in place and in good position an attempt was made to dilate the stricture with the coaxial dilator. However, the stone was right next to the mild stricture and would not permit the dilator to easily pass that point. The dilator was then removed and an attempt was made to pass the ureteroscope up again. The ureteroscope easily advanced up to the tight area, but was unable to transverse it. The stone could be visualized a few mm ahead, but the scope could not be easily advanced past the tightness in the ureter. At this point after multiple attempts to advance the scope, the procedure was stopped.” The urologist stated that he then continued on to place a JJ stent, and the stone went further proximally. So the intent was to get the stone, the stone dislodged further and because of the stricture he could not get the stone, stopped the procedure and placed a stent. Can I code 52330 with 52332 or do I just code the 52332?

Codify Forum Member

Answer: The intent of this procedure was to remove the ureteral stone. However, a ureteral stricture was found and could not be dilated. After a repeat ureteroscopy, a double J stent was passed and the stone was pushed proximally. However, since there was no actual cystoscopic attempt to manipulate the stone, and the stricture could not be dilated, you should not consider billing for either of these two procedures.

Instead, use the following coding for this scenario:

• 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic) for the ureteroscopy and,
• 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) for the placement of the double J stent.