Urology Coding Alert

Question: The urologist performed a ureteral stent placement. Later that evening he was called back to the OR to perform a pelvic exploration to evaluate for a bladder injury during a procedure already in progress on the same patient. These are separate encounters which initially led me to believe that modifier XE would be appropriate. However, now I see that code 52332 for the stent placement carries a 90-day global period. How should I report the second encounter?

Oregon Subscriber

Answer: According to the 2020 Medicare RBRVS manual, CPT^® code 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)) has a global period of 0 days rather than a 90-day global period. Therefore, in the situation you describe, report 52332 for the initial procedure. Then also file with 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure)) without a modifier for the latter surgery.

When coding this scenario, remember that Medicare and other insurers do not distinguish procedures performed on the same day at different times. Because of this, submit 49000 as the primary procedure and 52332 as the secondary procedure on a single claim submission.