Urology Coding Alert

Tip: Pay attention to dilation approach. 

One word can make all the difference in your coding success or failure when it comes to ureteral dilation procedures. 

Review this case study and how noticing just one word in the operative note changes the coding. Follow our expert tips to ensure you don’t miss any key points in your urologist’s documentation. 

Scenario: Your urologist is treating a patient with left renal colic, left ureteral stone, and stricture. He performs a cystoscopy, retrograde pyelogram, balloon dilation of a lower ureteral stricture under radiological contrast guidance, ureteroscopic extraction of the ureteral stone, and JJ stent placement. 

Capture Extraction With 52352

When assigning codes for this procedure, start with the stone extraction. You should report 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]) for the ureteroscopic extraction, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. 

Attach diagnosis code 592.1 (Calculus of ureter) to this procedure. 

Support 52332 With Prophylactic Diagnosis Indicator

For the stent insertion, you should bill 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]). You’ll use two diagnosis codes with 52332. First, list 591 (Hydronephrosis), and second list V07.8 (Other specified prophylactic or treatment measure).

Reporting V07.8 is “using a combination of ICD-9 codes to explain the placement of the stent prophylactically to prevent hydronephrosis,” Ferragamo says. 

Remember 26 for Retrograde Pyelogram Reading

To capture payment for the urologist’s work reading and interpreting the retrograde pyelogram, report 74420 (Urography, retrograde, with or without KUB). 

Append modifier 26 (Professional component) to the 74420, since your urologist read and interpreted the x-ray, but the facility owns the equipment, Ferragamo advises. Attach 592.1 as your diagnosis code. 

Note: The performance of the retrograde study (52005, Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) is bundled into 52332, and you cannot override this edit with any modifier. Therefore, in this clinical scenario, do not bill 52005 for the performance of the retrograde study.

Determine Dilation Type

In order to report the dilation of the lower ureteral stricture, you first need to scour the documentation to determine the approach your urologist used for the procedure. Your coding will change depending on whether your urologist used a cystoscopic balloon dilation alone without ureteroscopy or a ureteroscopic balloon dilation.

For only a cystoscopic approach, report 52341 (Cystourethroscopy; with treatment of ureteral stricture [eg, balloon dilation, laser, electrocautery, and incision]). For a ureteroscopic approach, report 52344 (Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture [eg, balloon dilation, laser, electrocautery, and incision]). 

Don’t miss: To indicate that your urologist performed the dilation procedure under radiological contract and supervision guidance, regardless of the dilation approach, report 74485 (Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation). Append modifier 26 to indicate that the urologist performed only the interpretation of the radiological study. The facility that owns the equipment and will bill for the technical portion using modifier TC.

In either approach, attach 593.3 (Stricture or kinking of ureter) as the diagnosis code for both the dilation procedure and the radiological guidance. 

Modifiers: Note that CCI bundles 52341 into the 52352 extraction code, so you need to attach modifier 59 to 52341. If you are reporting 52344 instead, you’ll attach modifier 59 to break the bundle between 52344 and 52352 as well.  “This is a little unusual because 52344 is the higher paying code, but it is bundled into the lower paying code, 52352,” Ferragamo says. 

Depending on your payer, you may also need to use modifier 51 (Multiple procedures) on the secondary procedure codes. 

You will also change the order in which you report the procedures, based on the approach. Since 52344 and 52341 have different RVU values, the arrangement of the codes on your claim will differ. Here is how each final claim would look:

Cystoscopic Balloon Dilation:

• 52352 with 592.1
• 52341-59 with 593.3
• 74485-26 with 593.3
• 52332-51 with 591 and V07.8
• 74420-26 with 592.1.

Ureteroscopic Balloon Dilation: 

• 52344-59 with 593.3
• 74485-26 with 593.3
• 52352-51 with 592.1
• 52332-51 with 591 and V07.8
• 74420-26 with 592.1.

Tip: “If you do a dilation of the ureteral orifice or the lower ureter to facilitate the passage of the ureteroscope ... in other words, if the ureteral lumen is narrowed, but not a true stricture, you should not bill for the treatment of a ureteral stricture,” Ferragamo explains. “Unless you clinically have a pre-existing ureteral stricture at the ureteral orifice, lower ureter, or at the renal pelvis, you should not report a ureteral dilation when the dilation is to just facilitate instrument passage.”