Cystourethroscopy With Stent


Vol. 18 •Issue 6 • Page 11
Coding Corner

Cystourethroscopy With Stent

Do not code the ureteral catheterization procedure for the dye injection used for the pyelograms separately.

Preoperative Diagnosis: Bilateral ureteral obstruction from carcinoma of rectum

Postoperative Diagnosis: Bilateral ureteral obstruction from carcinoma of rectum;

hydronephrosis

Procedure Performed: Cystourethroscopy, bilateral retrograde pyelograms, replacement of bilateral ureteral stents and fluoroscopy

Anesthesia: Topical plus IV sedation

Operative Technique: The patient was placed on the OR table in the lithotomy position. Intravenous sedation was administered. The genitalia were cleaned and draped in a sterile fashion.

A 23.5 Wappler cystoscope was introduced into the bladder. The bladder appeared essentially normal. The stents were noted. The distal end of the left ureteral stent was grasped with a foreign body forceps. The distal end was brought out through the urethra and cystoscope and removed. A 0.035 Bentson guide wire was passed through the stent into the left renal area. The stent was removed. A 6 French access catheter was passed over the guide wire under fluoroscopic guidance into the left kidney. The guide wire was removed. Renografin solution was injected into the renal pelvis to visualize it. The guide wire was replaced, and the access catheter was removed. A 6 French soft double-J, 24 cm stent was passed over the guide wire under fluoroscopic guidance, into the left renal pelvis. The guide wire was removed. The cystoscope was reintroduced into the bladder. The distal end of the right ureteral stent was now pulled out through the urethra. Attempts to pass a guide wire through this stent were unsuccessful because of concretions within the stent. Therefore, the stent was removed. Then, a 0.035 guide wire was passed through a Bentson catheter up the right ureter. Initially, the guide wire would not go up the ureter because it met an obstruction at the superior aspect of the right sacroiliac region. Then the access catheter was placed up to this region and the guide wire removed. Renografin solution was injected.

Narrowing in the ureter and hydronephrosis above that level was observed. By repeat manipulation under fluoroscopic guidance, the guide wire was successfully passed into the renal pelvis. Then, the access catheter was manipulated up into the renal pelvis also. There was considerable difficulty in pushing the access catheter through the strictured area in the ureter. Again, once the renal pelvis was reached, the guide wire was removed.

Markedly hydronephrotic drainage of urine was noted from the right renal pelvis. Renografin solution was again injected. The guide wire was replaced and the access catheter removed. A 6 French firm, 24 cm double-J stent was passed up the right ureter under fluoroscopic guidance and positioned satisfactorily in the kidney. The distal ends of the stents were also in satisfactory position in the bladder. Free drainage of urine was observed from both stents.

The patient tolerated the procedure well and left the OR in satisfactory condition.

ICD-9-CM DIAGNOSES

Preoperative:

Bilateral ureteral obstruction from carcinoma of rectum

154.1 Malignant neoplasm of rectum

593.4 Other ureteric obstruction

Postoperative:

Bilateral ureteral obstruction form carcinoma of rectum

154.1 Malignant neoplasm of rectum

593.4 Other ureteric obstruction

Hydronephrosis

591 Hydronephrosis

CPT CODING

The patient has obstruction of the ureters. In the above procedure, a cystoscopy (bladder exam with a scope) was performed for the replacement of the ureteral stents. To assist with the stent placement, dye was injected into the ureters.

To find the code for this procedure, look first for the term Cystourethroscopy in the index of the 2008 CPT code book. You will see a long list of options but, as the operative report makes clear, the term Insertion is the one for which you are looking. After reviewing the four options below that term, you will see that Indwelling Ureteral Stent 50947, 52332 should be investigated further. Here’s what you will find when you turn to the Surgery/Urinary System section of the code book.

Under the subsection entitled Laparoscopy:

50947 Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and urenteral stent placement

Under the subsection entitled Transurethral Surgery, Ureter and Pelvis:

52332 Cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type)

The descriptions of the above codes will lead you to the correct code of 52332. To communicate that bilateral stents were placed, you must assign modifier 50 (bilateral procedure) for both the professional and technical components.

Note: The ureteral catheterization procedure for the dye injection used for the pyelograms would not be coded separately. The Medicare national correct coding initiative (CCI) edits state this procedure to be a component part of the stent placement.

Correct CPT Codes and Modifiers (when appropriate):

Facility: 52332-50 Cystourethroscopy, with insertion of indwelling ureteral stent

Professional: 52332-50 Cystourethroscopy, with insertion of indwelling ureteral stent

Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.