Revenue Cycle Insider

Question: If the ob-gyn placed catheters for identification of the ureters (52005) during a gynecological procedure, usually a hysterectomy, and then removed them at the end of the procedure, is 52005 billable?

Our ob-gyn wants to report 52005 in addition to the primary procedure, arguing there’s no National Correct Coding Initiative (NCCI) edit preventing it. But my understanding from the NCCI procedure-to-procedure (PTP) book is that 52005 isn’t separately billable when performed only for ureteral identification. The only guidance I’ve seen addresses bundling of 52005 and 52332, not this specific scenario.

We also found an AHA Coding Clinic reference, but that typically applies to hospital billing, not physician claims. Without a urologic diagnosis, I assumed medical necessity might be lacking, though others suggest it’s up to the payer.

Are there any CPT^® Assistant articles or other authoritative guidelines that clarify whether 52005 can be reported in this context?

South Carolina Subscriber

Answer: According to the American Urological Association (AUA) (AUA Update Series, Lesson 11, Volume 39, 2020), the use of stents prophylactically seems to add a slight amount of time to the surgical procedure with minimal complications and, although the overall low incidence of ureteral injury may not be lowered significantly by stent placement, early detection appears to be an advantage if injury does occur. With greater surgeon experience, iatrogenic injury rates decrease. The choice for prophylactic ureteral stenting is a surgeon preference based on multiple variables including complexity of case, anatomy, and experience.

That said, you technically could bill 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) for this prophylactic procedure, but keep in mind that this code was never added to CPT^® for this purpose. The clinical vignette describing the physician work used to add the code to the CPT^® book is as follows:

Turn on video monitors. Be sure all personnel are safely in lead aprons. Place flexible cystoscope. Inspect entire bladder. Locate ureteral orifice. Order indigio carmine to be administered IV and wait 5 minutes for the efflux. Insert flexible wire up the ureter and confirm fluoroscopically. Pre irrigate an open-ended ureteral catheter and advance over the wire. Remove wire. Inject the ureteral catheter with contrast and obtain radiographs or digital images. Assess the images for completeness and possibly reinject. Remove catheter and reinspect bladder for any damage. Drain bladder and remove endoscope.

Please be sure that your provider is documenting this part of the procedure completely — and it would also be helpful to add a note as to why it is medically necessary for this patient.

If you bill this code, you should not append modifier 50 (Bilateral procedure) because the basic procedure is an examination of the bladder and urethra (cystourethroscopy), which are not paired organs. The work relative value units (RVUs) assigned take into account that it may be necessary to examine and catheterize one or both ureters.

So, as a coder, you must ask yourself: Is a diagnostic cystourethroscopy being performed and documented as such? A statement like “scope placed” will not work, and there should be some description of the bladder and urethral findings.

If you do bill 52005, your diagnosis code will have to be Z40.8 (Encounter for other prophylactic surgery) unless you can also report an underlying medical need for the patient (such as previous surgical injury, presence of adhesions, etc., to further back up the need). Pull whatever details you can from the operative report and medical record to explain what your ob-gyn did and why.

Linking the diagnosis as the reason for the gyn surgery will get you a denial for medical necessity. If you look at any surgical text, you will clearly see that identification of the ureters is integral to any gyn procedure, so you may find that most payers consider the use of prophylactic ureteral catheters to prevent damage to be part of the procedure. Even the American College of Obstetricians and Gynecologists (ACOG) coding book has in the past stated that insertion of stents and catheters during a procedure is included.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor