Urology Coding Alert

Question: My physician is doing an ESWL, plus a ureteronephroscopy with holmium laser of the stones. He is performing the ESWL at the same time as the laser, on the same stone. He is working on the outside and inside of the body at the same time, using two different techniques. I have been advised that the holmium laser is still considered an unlisted procedure. Any advice?

California Subscriber Answer: Though this combination of procedures is rare, some urologists do choose to do these procedures at the same sitting. You should use 52353 (Cystourethro-scopy, with ureteroscopy and/or pyeloscopy; with lithotripsy) for the holmium laser procedure and 50590 (Lithotripsy, extracorporeal shock wave). Since 50590 is bundled into 52353, you'll need to break the bundle with modifier -59 (Distinct procedural service).

Once unbundled, 50590 is the higher-paying procedure, so sequence that first. Then report 52353 with modifier -51 (Multiple procedures).

Be sure to document the extra time and complexity necessary to support the unusual procedural circumstances and send the operative note and a cover letter if requested by the carrier.