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Urology Coding Alert

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Surgical Difficulties Leading to Second Physician

Published on Fri Sep 07, 2007

Question: We had a patient come in for cystoscopy with stent removal. He saw Dr. A, who couldn't remove the stent and referred the patient to Dr. B within the same practice. Dr. B saw the patient afterward and also found a urethral stricture. How should I code and bill for this?

North Carolina Subscriber






Answer: For the incomplete cystourethroscopy, you should report 52000 (Cystourethroscopy [separate procedure]) for the urethra examination and append modifier 52 (Reduced services) to indicate that your urologist didn't perform the full cystourethroscopy. In other words, for Dr. A, code 52000-52.

Regarding the second physician's services, he seems to have seen the patient in a separate session, performing a cystoscopy, urethral dilation and replacement of the double-J stent. For these services, you should code only 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) for the stent placement because the Correct Coding Initiative (CCI) bundles the cystoscopy, the urethral dilation and stent removal into the stent placement, and you cannot break the bundle with any modifier.

Bonus: Remember to also code for the urethrogram using 51610 (Injection procedure for retrograde urethrocystography), and if the urologist reads and documents his professional interpretation of the films in the medical records, also code 74450-26 (Urethrocystography, retrograde, radiological supervision and interpretation; professional component). Modifier 26 indicates the physician performed only the professional component, the interpretation or reading of the films.

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