Urology Coding Alert

Question: The urologist performed a cystoscopy and used a basket to remove a small stone from the patient’s bladder. Everything was intact; no crushing, fragmentation, laser, or fulguration was involved. The operative report reads, “… the scope was then retroflexed (in the bladder) and beneath the median lobe, there was a small bladder stone seen. I then placed a basket through the flexible cystoscope and was able to grab the stone and then pulled intact atraumatically without irritating the prostate or urethra itself.” I’m thinking code 52310 is appropriate, but also wonder if we should include an additional code due to the use of the basket. Or, would we do better to report 52344 since explanations with it mention using instruments through the cystoscope to perform procedures such as stone removal? What do you recommend?

Idaho Subscriber

Answer: Code 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) is absolutely correct for the procedure you describe. Additional instruments can be passed through the cystoscope to allow the physician to perform procedures, such as stone removal, bladder biopsy, resection of a bladder or prostate tumor, and cauterization. These additional instruments could include a basket, so using the basket does not necessitate another code.

The other code choice you mention, 52344 (Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture [e.g., balloon dilation, laser, electrocautery, and incision]), is a ureteroscopic procedure that is diagnostically driven to treat a ureteral stricture. If you don’t have documentation of ureteral stricture leading to the procedure, and no ureteroscopy was performed at the encounter, 52344 would be an inappropriate code to bill for the above clinical scenario.