Code This Cystourethroscopy With Lithotripsy Case
Question: A 65-year-old patient presented with recurrent left flank pain and hematuria. The CT scan revealed an 8 mm stone in the left ureter, near the ureteropelvic junction. The patient has a history of multiple kidney stones and has previously undergone lithotripsy. However, due to the size and location of the current stone, the urologist decided to perform a cystourethroscopy with ureteroscopy and pyeloscopy, followed by lithotripsy. The procedure is successful, and the stone fragments are removed. What procedure codes do I need to report for this encounter? Iowa Subscriber Answer: You’ll assign 52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)) to report this procedure. The urologist performed cystourethroscopy with ureteroscopy and pyeloscopy, as well as lithotripsy. Some coders may be tempted to report the lithotripsy with a separate code, such as 50590 (Lithotripsy, extracorporeal shock wave), but that is incorrect. Code 52353 includes all of the components mentioned in your question, including the lithotripsy. Lithotripsy is a procedure that sends shock waves or ultrasonic energy at kidney and other urinary tract stones to break up the calculi for easier passage through the urinary tract. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
