Urology Coding Alert

Hint: Start with the number of structures.

Coding for multiple urinary stones can seem complicated at times, but can be less stressful if you keep a few rules in mind. The first thing to remember? Pay attention to anatomic structures because the stone location plays an important role in guiding your code selection.

Remember Multiple Structures Equal Multiple Codes

“The stones need to be in separate structures before you can code separately for them,” explains Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri’s Department of Surgery in Columbia. “If you have multiple stones in a single location (such as a single kidney or ureter), you still code for only a single stone removal but want the documentation to reflect the level of work the urologist completes.”

Example 1: A patient goes to the OR for right ureteroscopy and laser lithotripsy. The urologist treats the stones in the right ureter and then places a ureteral access sheath and passes the flexible ureteroscope to the right renal pelvis. The physician treats five separate stones throughout the kidney.

You can report each service separately because the urologist treated multiple stones in separate structures of the urinary tract. Submit these codes and modifiers:

• 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included) with diagnosis N20.0 (Calculus of kidney)
• 52353 with modifier XS (Separate structure…) for Medicare or modifier 59 (Distinct procedural service) for private and commercial carriers, adding diagnosis N20.1 (Calculus of ureter)

Take note: The same procedure code (52353) is allowed on both lines of your claim because the stones were in separate structures (renal pelvic stones and ureteral stones). Although anatomically the renal pelvis and ureter are continuous structures, for coding purposes they are considered separate anatomical structures.

Example 2: The surgeon completes fragmentation of a calyceal stone and fragmentation of an ipsilateral renal pelvic stone with placement of a JJ stent. Because the stones are in the same organ/structure, bill only 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)) one time. 

Also: Do not charge for multiple procedures on one stone, such as manipulation and then fragmentation. Determine which of the procedures mostly accomplishes the intended surgery, and bill only for it. 

Watch Your Modifier Usage

Using different techniques to treat stones may justify using a different modifier.

Example 1: The surgeon performs ESWL for a renal pelvic stone and ureteroscopic fragmentation of an ipsilateral ureteral stone. Code 50590 (Lithotripsy, extracorporeal shock wave) with diagnosis N20.0 and 52353 with diagnosis N20.1. In this scenario, append modifier XU (Unusual non-overlapping service…) to 52353. These qualify as unusual, non-overlapping services since the physician used different equipment and different operative techniques.

Example 2: The urologist completes ureteroscopic fragmentation of a left renal pelvic stone and ureteroscopic extraction of an ipsilateral distal ureteral stone. Bill 52353 with diagnosis N20.0 and 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)) with diagnosis N20.1. Append to 52352 either modifier 59 (Distinct procedural service) for commercial or private payers or XS for Medicare. Since the treatment of the two stones uses two different procedures during the same ureteroscopy, code the two procedures using XS on the second stone in a different structure.

Example 3: Sometimes a claim might merit modifier 22 (Increased procedural services) when separate CPT^® codes are not appropriate. Using modifier 22 is appropriate when your documentation supports significant additional time or anatomical difficulty. Statements of time, such as “50 percent additional laser time” or “procedure took twice the normal amount of time to perform” can help support modifier 22 use. Train your providers to write details such as those noted above instead of general statements about time such as “the case took an additional 20 minutes to complete.” The more pointed the descriptions can be of the additional work involved, the better your chances at additional reimbursement.

Final point: Remember that Medicare rules for stone coding may differ from the rules of private and commercial insurers. Therefore, be sure to check with the various insurers when unusual clinical stone scenarios arise.