In one of my recent cases, there were three stones in three separate locations of the right kidney and one small stone on the left. I pulverized one with lithotripsy, then manipulated the second stone into position to perform lithotripsy on it. I then manipulated the third stone into position to perform lithotripsy on it. Following this, I flushed out the kidney thoroughly and could see no additional fragments. I inserted an indwelling stent on the right. I elected to insert a stent on the left side but did not perform any other procedures on the left. How do I code for that using the new code, 52356?
As with many cases, there are two answers to your question.
First, for charges to Medicare: Since there were three “non-contiguous” stones on the right, you should be able to charge for the primary procedure performed to remove each stone. However, according to the National Correct Coding Initiative, as stated in a recent letter to the AUA, you can no longer make separate charges to Medicare for the treatment of multiple stones on the same side. (We feel that the NCCI’s ruling overstepped its authority and is incorrect. The AUA is appealing the interpretation.)
You can charge separately for the stent insertion on the left. You would not be able to charge for any of the contributory procedures such as manipulation, flushing the kidney, fluoroscopy, or irrigation. Code 52356 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) includes the performance of lithotripsy and the insertion of the indwelling stent on the same side. In addition, one 52332 service (cystourethroscopy, with insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) was performed on the left side, so you would bill as follows:
Second, non-Medicare and in our opinion the correct coding: CPT directions and the actual definition of modifier –59 provides that if documentation supports a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual (CPT 2014 modifier –59) may be reported using modifier –59. Your question supports that three separate stones, in three different sites, were treated during the same day by the same individual. As such, correct coding would indicate that the service should be reported to non-Medicare payers following CPT correct coding directives as:
- 52353–59–76 (the –76 modifier alerts the payers that this is not a duplicate charge and may not be required by all payers)
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