Urology Coding Alert

Question: The patient was brought back to operating room and underwent general intravenous sedation. The patient was placed in the low lithotomy position. The urologist prepped the patient, and a time-out was performed. The urologist then inserted a 22-French rigid cystoscope into the urethra and advanced it to the bladder. The urologist identified a remaining ureteral stent. Encrustations from the ureteral stent had now fallen off and were in the bladder. The urologist removed the ureteral stent, discarded it, and used graspers to break up and remove the encrustations and stones. The urologist removed all stones and calcifications from the bladder and emptied the bladder. The patient was then returned to supine position and taken to the recovery room in stable condition. Which codes should I report?

Connecticut Subscriber

Answer: For the procedure, you would report the following codes:

• 52318 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm)) for the crushing and removal of the stones
• 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple) for the removal of the single stent

Don’t miss: You should append modifier XS (Separate structure) to code 52310.