Urology Coding Alert

Recently a reader contacted Urology Coding Alert and questioned the ICD-10 diagnosis we chose for the double J stent removal in the “You be the Coder” titled “Stent Removal Diagnosis” in the Vol. 17, No. 11 issue.

The published answer: In the reader question, we instructed you to use an ICD-10 code from the T19 family, such as T19.1XXA (Foreign body in bladder, initial encounter), for the removal of a ureteral stent.

The reader suggested using the diagnoses N20.1 (Calculus of ureter) instead, with or without Z46.6 (Encounter for fitting and adjustment of urinary device).

Response: Although the reader reached the diagnosis N20.1 using the alphabetic list and the tabular list of the ICD-10 manual, and this diagnostic scenario may be applicable for stent removal, it is probably more accurately descriptive of diagnoses for stent exchange in the treatment of a ureteral calculus (procedure code 52332, Cystourethroscopy, with insertion of indwelling ureteral stent [eg, Gibbons or double-J type]).

“We still feel for JJ stent removal alone — CPT^® code 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) — the most appropriate ICD-10 diagnosis indicating medical necessity for 52310 would be ICD-10 code T19.1XXA, as the distal loop of the JJ stent lies within the bladder cavity s a foreign body,” says Urology Coding Alert consulting editor Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook. “Z46.6 would be an informative additional ICD-10 secondary diagnostic code that one may also code.”

Thank you to the reader for their coding suggestion, allowing us to clarify and offer coders the options that might apply to different stent removal scenarios.