Urology Coding Alert

Question: The urologist performed a semi-rigid ureteroscopy to extract a stone from the left ureter and a flexible pyeloscopy to remove a second stone from the left kidney. They performed both extractions using basket retrieval. Additionally, they placed a ureteral stent via cystoscopy. Am I able to report both stone extractions since two different scopes were used? The patient had recently received extracorporeal shockwave lithotripsy (ESWL) and had a stent placed. Following the procedure, they experienced the formation of steinstrasse, a condition where a column of stone fragments obstructs the ureter. So, technically, my urologist was removing the stone fragments from the previous ESWL. How should I code this?

AAPC Forum Subscriber

Answer: When you review this scenario technically, you’ll note the ureteral stone originated from a fragment of the renal stone and subsequently moved into the ureter following the ESWL. This is a remnant of the renal stone, which was not completely fragmented by ESWL in the first place. Taking these points into consideration, you should only report 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)) for the removal of both stones from the left kidney.

However, you would append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to 52352 to indicate the remaining renal stones were a result of the ESWL, assuming the urologist performed the procedure during the 90-day global of the ESWL.

Here’s why: According to John Piaskowski, CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey, and AAPC consultant and committee chair, “you cannot add a second 52352 even though two different scopes were used. Per the CMS [Centers for Medicare & Medicaid Services] physician fee schedule, 52352 has an MUE [Medically Unlikely Edit] of 1 unit, which means it is considered medically unlikely that more than 1 unit would be submitted on the same date of service [DOS].” An exception to this would be if it is bilaterally performed, but in that case, you would append modifier 50 (Bilateral procedure) to the service and not code by an increase in units, Piaskowski explains.

CMS further categorizes 52352 with an MUE adjudication indicator (MAI) value of 2. Codes with an MAE value of 2 indicates an absolute DOS edit based on policy. Payers who apply the MUE sum the code’s same-DOS units. If the sum exceeds the MUE value, the payer will deny same-DOS lines with that code on the current claim. CMS has not identified any instances in which exceeding an [MUE Adjudication Indicator] (MAI) 2 MUE is correct. In other words, “there is no avenue to submit 52352 twice, nor are there any appeal rights per CMS should that claim be submitted as such and subsequently denied,” Piaskowski concludes.

The bottom line: For this scenario, code 52352 for the removal of the stone from the left kidney and append modifier-58 for the left ureteral stone extraction following the original ESWL.