No Stones found

[carol52]

Dr. Placed a double j stent on the left side of ureter after the patient had been scheduled for a left ureteroscopy/laser lithotripsy /stent
No stones were found so can only bill the Stent placement rt ?
Thanks,
Carol

 

[thomas7331]

Yes, you can only bill for what was performed, the ureteroscopy (assuming that was done) with stent placement.

 

[liqgold2@aol.com]

For the diagnosis in this case add for the reason for the ureteroscopy (not billed) such as ureteral stone, N20.1, and then a second diagnostic code Z71.1 for stone suspected but not found.
Michael A. Ferragamo MD, FACS, urologist and urology coding and reimbursement consultant.

 

[thomas7331]

For the diagnosis in this case add for the reason for the ureteroscopy (not billed) such as ureteral stone, N20.1, and then a second diagnostic code Z71.1 for stone suspected but not found.
Michael A. Ferragamo MD, FACS, urologist and urology coding and reimbursement consultant.

I don't believe Z71.1 would be an appropriate code to report for the encounter described above - that code is for is for an encounter in which a healthy and asymptomatic patient who has a 'feared health complaint' was evaluated but for which no diagnosis was ultimately made during the encounter. A patient wouldn't normally undergo a cystoscopy or ureteroscopy with a stent placement without a reportable diagnosis or symptom to make such a procedure necessary.