Urology Coding Alert

Question: I’m having a difficult time understanding the NCCI edits between codes 52346 and 52356. My physician performed the procedures on the same side, but NCCI says both are not reportable, and I understand that. What I don’t get is why the higher-valued procedure, 52346, looks like it is bundled into the lower-valued procedure, 52356. I’ve seen this in other situations as well. I have been driving myself crazy trying to find some guidance on this and must be missing it. Should 52356 be reported since it is the Column 1 code, or is it ok to submit 52346 since it is higher-valued? If you do that, you can then report the stents as well from what I am seeing, since 52332 is not bundled?

AAPC Forum Member

Answer: There are two ways you can bill this clinical scenario.

First, report code 52346 (Cystourethroscopy with ureteroscopy; with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision))-XU (Unusual non-overlapping service), the higher-paying code (but also the bundled code) as your primary procedure with modifier XU to unbundle the edit pair. Then you will report 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)) as the secondary code and receive full payment for the primary code 52346 and 50 percent payment for the secondary code, 52365.

Another method to bill these types of clinical entities is to report 52346 as the primary code without a modifier and to bill 52365 as the secondary code and append modifier XU to code 52356. You should receive payment in full for the primary code and 50 percent payment for the secondary code, which still is the lesser-paying code. This was a recent change the Centers for Medicare & Medicaid Services (CMS) made to rectify this coding problem.