Urology Coding Alert

Hint:  50590 applies to a stone in the kidney or ureter

Extracorporeal shockwave lithotripsy, or ESWL, is a common procedure that urologists perform, but many nuances can make coding the procedure less than common.

CPT Code 50590 (Lithotripsy, extracorporeal shock wave) seems fairly self- explanatory. However, where the stone is located, how many stones there are, and whether the physician also places a stent can make coding a challenge. Take a look at our expert's answers to your top ESWL questions and solidify your coding. Limit How Often You Report CPT 50590 Question: Our urologist performed ESWL on multiple stones in the patient's kidney during the same operative session. Should I report 50590 for each stone? Answer: The simple answer is no. You cannot report 50590 multiple times for one session based on the number of stones the urologist must fragment. The same CPT code applies even if the stones are in multiple locations within the same kidney or corresponding ureter.

Example: A patient has a stone in his left kidney, so the urologist performs an ESWL. During the procedure, the physician discovers another stone in the left ureter and proceeds to fragment that stone as well.

While you may be tempted to report 50590 twice because there were two stones, each in a different location, you should only report it once. The relative value units (RVUs) for 50590 are assigned to accommodate instances when the urologist treats single or multiple stones in the same kidney and/or ureter. Remember that when you're  fragmenting stones with ESWL, the kidney and corresponding ureter are considered the upper urinary tract and the bladder the lower urinary tract.

Helpful hint: If a patient has stones in both kidneys, the urologist will usually perform two separate procedures at different times. The physician should write in the op note of the first ESWL that he plans to perform a second procedure on the other side in a few weeks. This indicates to your payers that the urologist planned, or staged, the two operative sessions.

You'll therefore report the first procedure with 50590 and then report the second procedure with 50590, appending modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to indicate the staging, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stony Brook. Code 50590 has a 90-day global period.

Remember: You should also use modifiers LT (Left side) and RT (Right side) to indicate which side the urologist operated on during which session. In other words, if he performs the ESWL on the right side first, you'd report 50590-RT and then 50590-LT-58 for the second procedure.

Alternative: If the [...]