Vol. 14 •Issue 18 • Page 15
Coding Corner
Coding Urology System Case Studies
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. He was placed on the lithotripsy table in a supine position. 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 then 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 the grasping forceps were used. 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 ICD-9-CM Diagnosis: Right renal stone
592.0 Calculus of kidney
Postoperative ICD-9-CM Diagnosis: Right renal stone
592.0 Calculus of kidney
CPT Code Assignments
The patient was first taken to the lithotripsy unit to break up the stone. Check the term Lithotripsy in the CPT manual index, and look then under term Kidney where codes 50590 and 52353 are listed. After reading the descriptions of the codes, you will see that code 50590 is the most appropriate for assignment.
For the technical component of the procedure, you would append modifier RT to communicate that the lithotripsy procedure was performed only on the right kidney. No modifier is used for the professional component.
After this portion of the procedure was completed, the patient was taken to the cystoscopy suite where a cystoscopy procedure was performed to remove the indwelling ureteral stent from the patient’s ureter.
Refer to the term Cystourethroscopy then Removal in the CPT manual index. Urethral Stent and code range 52310-52315 is listed. After reading the code descriptions, you will see that the code 52310 is appropriate.
For the facility component, you will need to first assign modifier 59, distinct procedural service. Modifier RT also will be assigned to communicate that the stent removal was a completely separate procedure from the lithotripsy and that the stent was removed from the right ureter. For the professional component only modifier 59 is required.
Facility Code Assignments
50590-RT Lithrotripsy, extracorporeal shock wave
52310-59-RT Cystourethroscopy, with removal of foreign body, calculus or ureteral stent from urethra or bladder (separate procedure); simple
Professional Code Assignments
50590 Lithrotripsy, extracorporeal shock wave
52310-59 Cystourethroscopy, with removal of foreign body, calculus or ureteral stent from urethra or bladder (separate procedure); simple
Case Study 2
Preoperative Diagnosis: Recurrent bladder tumors and vesical neck contracture
Postoperative Diagnosis: 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, 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. The 25 French resectoscope then was inserted. The bladder neck was incised at the 5 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, and none was replaced.
ICD-9-CM Code Assignments
Preoperative ICD-9-CM Diagnosis: Recurrent bladder tumors and vesical neck contracture
239.4 Neoplasm of unspecified nature, bladder
596.0 Bladder neck obstruction
Postoperative ICD-9-CM Diagnosis: Recurrent bladder tumors of the lateral wall and vesical neck contracture
239.4 Neoplasm of unspecified nature, bladder
596.0 Bladder neck obstruction
CPT Code Assignments
The cystoscopy procedure was performed for the recurrent bladder tumors. The bladder neck contracture was found on cystocospy. The cystoscope was removed, but the resectoscope was inserted, and the contracture was incised. Then the resectoscope was moved into the bladder to biopsy/fulgurate the small bladder lesions.
First refer to the term Cystourethroscopy and the indented term with Fulguration in the CPT manual index. Codes 52234-52240 are listed, and when you read the descriptions, you will see that the correct assignment would be 52234.
Next, for the incision of the bladder neck, refer to the term Urethra followed by Unlisted Services and Procedures. Code 53899 is listed, and this is the correct code.
Facility Component
No modifiers are required for the facility component to which you will assign the above-identified codes.
52334 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 to 2.0 cm)
53899 Unlisted procedure, urinary system
Professional Component
For this component, you will need to assign modifier 51, multiple procedures, to the second code as shown below.
52334 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 to 2.0 cm)
53899-51 Unlisted procedure, urinary system
Kathy Mundy is manager of consulting services, physician division, for Medical Learning Inc. (MedLearn®), St. Paul, MN.
