Billing for lithotripsy of upper ureter stones followed by URS in the kidney

Jonathan Rubenstein, MD

How would I report the following scenario: A holmium laser was used to perform laser lithotripsy of the upper ureter stone. A stone basket was used to extract the fragments, although many did wash into the kidney. Ureteroscopy was then performed up into the kidney to further laser the fragments that had gone up, along with lasering a 4 × 2-mm lower pole stone that was seen. After lasering and extraction, a 6 × 28-cm ureteral stent was then placed. Would it be appropriate to report CPT code 52356 (with International Statistical Classification of Diseases, Tenth Revision [ICD-10] code N20.1) along with CPT code 52353 (with modifier XS, ICD-10 code N20.0 in this scenario), or is it more appropriate to only report 52356 because the original stones occurred in ureter and then washed into the kidney?

Mark Painter

We will add this question to the continuing saga and changing world of CPT coding.

CPT code 52356 describes “cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type).” The code descriptor does not in itself describe any specific number of stone(s) that are lasered or the location of the stone(s) for reporting purposes. So the question is whether CPT code 52353 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]) can be reported for either stones that were originally in the ureter and then flushed up into the kidney, and/or whether CPT code 52353 could be reported for lasering the separate and identifiable 4×2-mm stone that was in the kidney, not in the ureter. Some, including the American Urological Association, have argued that the ureter is a separate anatomic structure from the kidney and therefore different stones represent different work, and both could be reported. Additionally, the National Correct Coding Initiative does allow unbundling with a modifier if codes 52356 and 52353 are reported on the same date. We have therefore argued in the past that reporting both stones, if located in separate anatomic areas, may be allowed by some payers.

However, this argument does not fully acknowledge the CPT codebook parenthetical beneath CPT code 52356, which provides further coding guidance, stating, “Do not report 52356 in conjunction with 52332, 52353 when performed together on the same side.” This parenthetical clarifies CPT code 52356 (but not CPT 52356 with 52353) would be reported for cystoscopy with ureteroscopy and stent placement, no matter the size, location, or number of stones treated. Therefore, from a CPT perspective, it does not matter whether the stone was flushed up to the kidney and further ureteroscopy was needed nor whether there was a separate identifiable stone; in both cases, only CPT 52356 would be reported.

CPT is the base or foundation of communication for payment of health care services in the United States. Payers, including Medicare, have layered payment rules and interpretation of CPT codes, notes, and guidelines on top of those included in the CPT manual. Many of these interpretations do not fully consider the true intention of CPT and the nuances of health care that the American Medical Association attempts to address in the categorization of services in health care. An increasing number of payers are adopting a more rigid CPT code interpretation to include the parenthetical notes. Unfortunately, most payers are now consistently considering that stones, regardless of location prior to or during the procedure, are accurately represented by reporting 52356 once and no longer allowing 52353 for treatment of a second stone.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.