Urology Coding Alert

Question: Our doctor conducted a cystoscopy, a right retrograde pyelogram, and a right ureteroscopy to place a stent. However, during postoperative imaging, it was discovered that the stent was not properly positioned. As a result, the patient had to undergo a stent removal procedure in the operating room the following day. Should I include the stent removal in the report? If yes, should I use modifier 58 or 78?

Wyoming Subscriber

Answer: Yes, you should report the stent removal procedure. However, the modifier you use — and even the use of a modifier — will depend on the specific circumstances. For example, if the provider planned the stent removal and performed it during the same operative session as the initial procedure (cystoscopy, retrograde pyelogram, and ureteroscopy), you should use modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period). This modifier indicates that the removal was a planned procedure during the global period of the initial surgery.

On the other hand, if the stent removal was unplanned and required a return to the operating room on the next day, you should use 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). This modifier indicates that the removal was a related procedure performed due to a complication or problem arising from the initial surgery. Remember, it’s crucial to accurately document the medical necessity and reason for the stent removal in the patient’s medical record. This documentation will support the appropriate use of the modifier and ensure proper reimbursement.

Let’s take an even deeper look at how to code this procedure correctly.

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.

Because the stent was found to be incorrectly positioned, you would consider this a complication of the original surgery. Therefore, you should consider using modifier 78 for payment if the provider performs the procedure on the same day as the cystoscopy or ureteroscopy. 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).