Urology Coding Alert

Stent insertion 52332 (cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) presents many coding quandaries because it usually is done in relation to other procedures, and it is unclear whether you can bill separately for the stent. Since 52332 is proposed to be increased by $450 over the next two years (see Code 52332 to Increase By $450 on page 60 in the August 2000 Urology Coding Alert), its going to be especially important for urologists to know how to bill it correctly.

If you put in a temporary ureteral catheter or attach to a Foley, you cant bill for the stent, says Jules Geltzeiler, MD, who practices with Shore Urology in Long Branch, N.J. But if it is a permanent stent, you can bill separately.

For example, if a urologist removes a stone from the ureter and bills using 52336 (cystourethroscopy, with ureteroscopy and/or pyeloscopy [includes dilation of the ureter and/or pyeloureteral junction by any method]; with removal or manipulation of calculus [ureteral catheterization is included]), you also can bill for 52332, but you must append modifier -59 (distinct procedural service) to the 52332.

In fact, Geltzeiler says it is possible for urologists to get paid for a stent even if they are putting it in for the same reason they are performing the other procedure, such as the ureteral stone removal (52336). Thats because when Medicare figured out the work value for a stone removal, it did not include the work value for a stent, says Geltzeiler.

Carol Hutson, office manager with Germantown Urology Center of Germantown, Md., recommends that coders always check with their Medicare carriers before determining how to bill a permanent stent insertion, as well as billing for other procedures. I always refer back to Medicare, she says. I have a list of documentation checks, including whom I have talked to there. But after double-checking with her carrier, she says that in general, Medicare will pay separately for the stent with a modifier -59.

Separate Diagnosis Unnecessary

Some urology coders think that you need to have a separate diagnosis to get paid for the stent insertion, but you dont. CPT has determined that the insertion of an indwelling stent is a distinct procedure and should be charged separately even if for a related reason, says Ray Painter, MD, president of PRS, a coding, compliance and reimbursement consulting firm based in Denver. Medicare should not require a separate diagnosis, says Painter, a urologist.

But if the stent needed to be inserted because two days after the ureteral stone was removed the patient was experiencing retention, then you could bill for the stent insertion. The diagnosis code for the stone removal is 592.1 (calculus of ureter). The diagnosis codes for retention are 788.20 (retention of urine, unspecified), 788.21 (incomplete bladder emptying) and 788.29 (other specified retention of urine).

Usually, the stent is being left in for a different reason than the reason the procedure is being done, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding and reimbursement consulting firm based in Denver. For example, the urologist is leaving the stent in to prevent a stricture. The ureter needs to be kept open, and the stent is inserted for that reason. Its a different reason from the stone removal. You need to use a modifier -59 because the stent is a distinct procedure.

But if its a matter of practice, and the urologist routinely inserts a stent, then you cant use a modifier -59, and you cant get paid for it, says Page. If the stent is being inserted as a matter of course, you should not be billing Medicare for it separately.

Private payers, however, are different. You should bill private payers for the stent insertion, regardless of whether it is related to the other procedure, says Page.

Removal of Stent

When the stent needs to be removed, you should bill with 52310 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) with modifier -58 (staged or related procedure or service by the same physician during the postoperative period) appended. Its clearly a staged procedure, notes Geltzeiler, because you knew you would take it out when you put it in. Also, CPT specifically advises 52310-58 for coding stent removal.

Another common stent scenario is the stent that must be inserted after a lithotripsy (50590). There is swelling and retention after the procedure. The urologist needs to insert a double-J stent. Modifier -59 is unnecessary, says Painter, because 50590 and 52332 no longer are bundled.

Note that when both 50590 and 52332 are billed in the same session, the payer most likely will reduce payment for the multiple procedure, says Page. There are some coders who feel that modifier -59 should garner 100 percent of the allowable even when billed with another surgical procedure, the consultant notes. And I have seen some explanation of benefits (EOB) where the payer did indeed pay 100 percent. But, she adds, this is rare.

Tip: Know the codes that 52332 is bundled with: 50081, 50230, 51715, 51845, 52234, 52235, 52240, 52281, 52301, 52320, 52335, 52336, 52337, and 52338.