Urology Coding Alert

Question: What is the best way to code for pouchoscopy with removal of a right ureteral stent?

New Jersey Subscriber

Answer: There are two possible ways to code for this clinical scenario.

Method 1: Submit CPT^® code 44385 (Endoscopic evaluation of small intestinal pouch [e.g., Kock pouch, ileal reservoir {S or J}]; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) and append modifier 22 (Increased procedural service) for the extra work involved with removing the stent. It may also be necessary to submit the operative report to the insurer as well as a cover letter explaining in layman’s terms what was performed and why. The diagnostic code should be T18.3XXA (Foreign body in small intestine, initial encounter).

Method 2: Since the urinary pouch represents a substitute urinary bladder, one may use code 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder; simple) with modifier 52 (Reduced services) appended to indicate that a cystourethroscopy was not performed. Then include 44385 for the pouchoscopy that was performed instead of the cystoscopy. Append ICD-10 diagnostic code T19.1XXA (Foreign body in bladder, initial encounter) to 52310 and T18.3XXA to 44385.

Remember: CPT^® 2015 changed the wording in the official descriptor for 44385 and the associated code 44386 (… with biopsy, single or multiple). The wording makes clear that the pouch being examined is usually a “small” intestinal pouch and supports this with specific examples (Kock pouch and ileal reservoir, S or J type). Code 44385 also changed “with or without collection of specimens” to “including collection of specimens when performed.” You should not report the collection of specimens separately, but the procedure itself is separate from any other procedure that might be performed at the same time.