Urology Coding Alert

Question: My doctor is often called in to check patients' ureters when an ob/gyn performs surgery. Most of the time he just has to check the unharmed ureter and leave, no opening or closing of the patient is required. He doesn't write it up as a consult, so I can't figure out how to code this. I am thinking about adding modifier -52 (Reduced services) to a ureter code, but which one?

Michigan Subscriber

Answer: You should code ureteral exploration with code 50600-52 (Ureter-otomy with exploration or drainage [separate procedure]) indicating the ureteral exploration but not the ureterotomy.

In this particular case report only code 50600-52 because no consultation was recorded. Be sure your urologist has dictated his operative report so a charge can be made. You should not report the urologist as an operative assistant because there is usually another physician acting as an assistant, and most carriers will allow and pay for only one assistant.

Answers to You Be the Coder and Reader Questions contributed by Sandy Page, CPC, CCS-P, co-owner, Medical Practice Support Services, Denver; and Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.