Urology Coding Alert

Question: I have a question about the following note, which describes a procedure that the urologist recently performed.:

Diagnosis: Need for left ureteral catheter for identification

Procedure: Cystourethroscopy, left ureteral stent placement for identification with injection of ICG (Indocyanine-green). Detailed Description of Procedure: This is a 53-year-old male admitted for scheduled retroperitoneal mass removal per general surgery. Urology was requested to place a left ureteral stent for intraoperative identification, as well as injection of ICG. Patient was brought to the operating room placed on the table in supine position. Anesthesia was induced and preoperative antibiotics were given. He was transferred to dorsolithotomy position, prepped, and draped in normal sterile fashion. Timeout was then performed. Rigid cystoscope was inserted to the urethra and advanced towards the bladder.

There were no abnormal findings in the urethra or the bladder. We turned our attention to the left ureteral orifice and cannulated this with a 5 French open-ended ureteral catheter. The ureteral catheter was advanced about halfway into the left ureter and injected approximately 3cc of ICG. Instruments were then removed, and a 16 French two-way Foley catheter was placed. Angiocath was used to insert the distal end of the ureteral catheter into the Foley drainage bag. Ureteral catheter was affixed to the urethral Foley with umbilical tape. This concluded the urology portion of the procedure. General surgery then proceeded with their portion of the procedure. General surgery will remove ureteral catheter at the end of the case.

These are the codes that I have: 52005 with a diagnosis code of Z46.6. I am thinking that the ICG (Indocyanine-green) injection is bundled into 52005 but would love clarification to be sure.

Wisconsin Subscriber

Answer: You are correct. The only code that would apply in this situation is 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service). This code includes instillation of contrast materials. per the code description. “Part of the clinical responsibility is to instill fluids, such as saline, into the bladder, irrigate the bladder, and/or introduce a contrast medium to facilitate the visualization or radiological study of ureteric and renal pelvic structures,” says John Piaskowski, CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey and surgical coding consultant at Memorial Care Health System in Huntington Beach, California.

You would also report Z46.6 (Encounter for fitting and adjustment of urinary device) for the primary diagnosis, as you suggest.

Pay attention: “In the note, the provider indicates that the purpose of the procedure was to place a ureteral stent. But nowhere in the operative note does it mention that a stent was placed. A catheter does generally serve the dual function of expanding the ureter and facilitating drainage, but it does appear confusing to the reader that the purpose of the surgery wasn’t performed as listed. Since you coded per the body of the report, this isn’t really of concern, however. This is more of a teaching moment to the provider from you as the coder,” said Piaskowski.