Urology Coding Alert

You Be the Coder:

Ureteral Foreign Body Removal

Published on Mon Nov 10, 2014

Question: My doctor performed surgery where “ureteroscopic laser lithotripsy was done for a distal stone. It was found that the cause of the stone was a surgical staple from a prior hysterectomy that had eroded into the ureteral lumen. Once the stone fragments were removed, considerable amount of time was spent with the aid of the holmium laser and various ureteroscopic baskets in an attempt to un-roof the surgical staple and completely remove it. Eventually this was able to be successfully performed, and no further foreign bodies were seen in the remaining ureteroscopic exam.”

I am not sure how to code this section. It seems to be that this is a separate procedure from the actual stone removal process. What should I report?

California Subscriber

Answer: Unfortunately, there is no CPT® code for the removal of a foreign body from the ureter. For your clinical scenario, report the following:

52353 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]) for the fragmentation and removal of the ureteral stone
52344 (... with treatment of ureteral stricture [eg, balloon dilation, laser, electrocautery, and incision]) for the ureteral incision to un-roof the ureteral wall foreign body and its removal.
Append modifier 59 (Distinct procedural service) to 52344 to break the bundle between the two codes.
Report diagnosis codes 592.1 (Calculus of ureter) and 939.0 (Foreign body in bladder and urethra).