Urology Coding Alert
Removal of Ureteral Fungal Ball
Question: How would you code a ureteroscopy with removal of a fungal ball? The patient had a fungal bezoar of the ureter coded with diagnosis code 939.9.
Pennsylvania Subscriber
Answer: There is no CPT® code for ureteroscopic removal of a foreign body from the kidney or ureter, such as a fungal ball in the kidney or ureter.
What to do: If the foreign body is calcified to any extent, code for removal of a stone with 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]). If the foreign body is not calcified, then report 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic).
Append modifier 22 (Increased procedural services) to the chosen procedure code if the time to remove the foreign body did take a significant amount of time. Keep in mind, however, that adding modifier 22 will delay payment and increase your work to get the claim paid.
Diagnosis code 939.9 (Foreign body in unspecified site in genitourinary tract) would be appropriate for the fungal ball in the ureter.
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