Vol. 17 •Issue 8 • Page 13
Coding Corner
Coding Urinary System Procedures
Be very cautious about assigning modifier 59 (distinct procedural service) to identify separate procedures.
Case Study 1
Preoperative Diagnosis: Right renal stone
Postoperative Diagnosis: Right renal stone
Procedure Performed: Extracorporeal shockwave lithotripsy; cystoscopy with double-J stent removal
Indication for Procedure: The patient is a 71-year-old male who had undergone shockwave lithotripsy and stent placement previously for a partial staghorn calculus. The first lithotripsy fragmented approximately 50 percent of the stone, and he is presenting now to have the remainder of the stone treated.
Operative Technique: The patient was taken to the lithotripsy unit initially and placed on the lithotripsy table in a supine posi-tion. Following induction of anesthesia, fluoroscopy was used to position the patient where the stone was visualized in the focal point of the shockwaves.
Once the patient was adequately positioned and the stone was well visualized in the lower pole calyx, shockwave lithotripsy was performed. He was given a total of 4,000 shocks with a maximum power setting of 3.0. Intermittently, the position of the stone was checked with fluoroscopy.
Following completion of 4,000 shocks, the patient was then transferred to the cystoscopy suite. The patient was then placed in the dorsal lithotomy position. The external genitalia were prepped and draped in sterile fashion. The cystoscope was inserted through the urethra into the bladder. The double-J stent was visualized and grasped with the grasping forceps. The stent was then extracted as the scope was pulled out. At this point, the procedure was terminated and the patient was transferred to the recovery room in satisfactory condition.
ICD-9-CM CODE ASSIGNMENTS
Preoperative and Postoperative ICD-9-CM Diagnoses: Right renal stone
592.0 Calculus of kidney
CPT Code Assignments and Rationale
The patient was first taken to the lithotripsy unit to break up the stone in the kidney.
In the index, you will see Lithotripsy listed, and one of the choices under it is Kidney — 50590, 52353. After reading the code descriptions, you will see that the correct choice is 50590. Because the lithotripsy procedure was performed only on the right kidney, you will need to assign modifier RT (right side).
After this portion of the procedure was completed, the patient was taken to the cystoscopy suite where a cystoscopy was performed to remove the indwelling ureteral stent from the patient’s ureter. Check the index for the term Cystourethroscopy under which you will find the term Removal. Urethral Stent — 52310-52315.
After reading these code descriptions, you will see that 52310 is the appropriate code. You will need to assign modifier RT (right side), which communicates that the stent was removed from the right ureter.
Facility code assignments look like this:
50590-RT Lithotripsy, extracorporeal shock wave
52310-RT Cystourethroscopy, with removal of foreign body, calculus or ureteral stent from urethra or bladder (separate procedure); simple
Professional code assignments are slightly different.
50590 Lithotripsy, extracorporeal shock wave
52310-51 Cystourethroscopy, with removal of foreign body, calculus or ureteral stent from urethra or bladder (separate procedure); simple
Add modifier 51 (multiple procedures) to the second professional code to indicate that multiple procedures were performed.
Although code 52310 was a separate procedure, coders should be very cautious about assigning modifier 59 (distinct procedural service) to identify that fact. According to the Department of Health and Human Services Office of Inspector General, providers are inappropriately using the modifier to bypass the national correct coding initiative (CCI) edits. Even though there is no CCI edit for this code, assignment of modifier 59 should be used with caution if used at all.
Case Study 2
Preoeprative Diagnoses: Recurrent bladder tumors and vesical neck contracture
Postoperative Diagnoses: Recurrent bladder tumors of the lateral wall and vesical neck contracture
Procedure Performed: Cystoscopy with biopsy and fulguration of the bladder tumors and transurethral incision of vesical neck
Anesthesia: General
Operative Technique: This male patient was placed on the cystoscopy table and administered a general anesthetic and placed in the lithotomy position. The genitalia were prepped and draped in the usual fashion.
The 17 French cystourethroscope was inserted under direct vision. The anterior urethra was normal. There was a contracture of the bladder neck that could be negotiated with the scope. Inspection of the interior of the bladder with the right angle lens showed multiple reddened areas and two small superficial appearing tumors.
The cystoscope was then removed, and the urethra was dilated to 28 French and the 25 French resectoscope was inserted. The bladder neck was incised at the 5 o’clock and 7 o’clock positions to allow it to drop widely open. The small tumors, one measuring 0.6 cm and the other measuring 0.9 cm were biopsied and then fulgurated. A final check was made for bleeding, and the resectoscope was removed.
A 20 French Foley catheter was placed in the bladder. Returns were clear. The patient tolerated the procedure well and went to the recovery room in satisfactory postoperative condition. Blood loss was minimal; none was replaced.
ICD-9-CM Code Assignments
Preoperative and Postoperative Diagnoses: Recurrent bladder tumors and vesical neck contracture
239.4 Neoplasm of unspecified nature, bladder
596.0 Bladder neck obstruction
CPT Code Assignments and Rationale
The physician performed a cystoscopy for the recurrent bladder tumors.
A bladder neck contracture also was found. The cystoscope was removed, and a resectoscope was inserted. The contracture was incised, and the resectoscope was moved into the bladder to biopsy/fulgurate the small bladder lesions.
Go to the index and find the term Cystourethroscopy. You should then look for the term “with Fulguration” under which are two terms; the correct choice, of course, is “Tumor.” After reading the code descriptions listed (52234-52240), you will see that code 52234 is correct.
For the incision of the bladder neck, check for the term Urethra followed by Unlisted Services and Procedures. Assign code 53899, and add modifier 51 (multiple procedures) to the second professional code.
For the facility component, assign the following:
52234 Cystourethroscopy, with fulguration and/or resection of; SMALL bladder tumor(s) (0.5 to 2.0 cm)
53899 Unlisted procedure, urinary system
The following should be assigned for the professional codes:
52234 Cystourethroscopy, with fulguration and/or resection of; SMALL bladder tumor(s) (0.5 to 2.0 cm)
53899-51 Unlisted procedure, urinary system
Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn®), St. Paul, MN.
