Can you report CPT 52352 when removing fragments of a stone lasered in the ureter?

I have providers who believe they should be allowed to report CPT 52352 when removing fragments of a stone they just lasered in the ureter. I have explained that the removing the lasered stone fragments is inherent to the lithotripsy code (52356 or 52353) when removing fragments so cannot be reported separately. What is the right answer?

Jonathan Rubenstein, MD

You are correct. We all agree with the nuances of coding that there can be confusion if there is no specific language within a CPT code that specifically restricts reporting one code with another code, and in this case one may be looking for the language that specifically restricts the separate reporting of stone removal with lasering that stone. More specifically to this discussion, CPT code 52356 (cystourethroscopy, with ureteroscopy and/or pyeloscopy with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) specifically states, “Do not report 52356 in conjunction with 52332, 52353 when performed together on the same side,” so we are made aware to not report stent placement or laser lithotripsy separately for work done on the same side, but the code does not explicitly exclude CPT code 52352 (cystourethroscopy, with ureteroscopy and/or pyeloscopy with removal or manipulation of calculus [ureteral catheterization is included]). Yet, despite not being stated, removing the lasered stone fragments is part of 52356 and

Mark Painter

cannot be reported separately. We need to consider 2 separate parts of CPT to arrive at the answer, and of course, we must consider payer rules that build upon the foundation of CPT guidelines.

One way of thinking about this is that the family of codes works its way up stepwise, with each procedure encompassing the lesser procedures to get to that point. The lesser procedure(s) are included in the bigger procedures, so they should not be reported separately.

We like to think of it like this:

• 52000 – cystoscopy

• 52005 – cystoscopy with ureter catheterization (do not report 52000 if reporting 52005)

• 52351 – ureteroscopy, diagnostic (do not report 52000 or 52005 if reporting 52351)

• 52352 – ureteroscopy with stone manipulation/extraction (do not report 52000, 52005, or 52351 if reporting 52352)

• 52353 – ureteroscopy with laser lithotripsy (do not report 52000, 52005, or 52351 if reporting 52353; do not report 52352 for extraction of the lasered stone)

• 52356 – ureteroscopy with laser lithotripsy and stent (do not report 52000, 52005, 52351, or 52353 if reporting 52356; do not report 52352 for extraction of the lasered stone).

CPT coding aims to report a typical procedure with 1 CPT code when possible. For example, removal of lasered stone fragments, such as using a basket, is part of the typical performance of laser lithotripsy of a stone. When valued by the RVS Update Committee (RUC), 52356 included the time and value of removing the stone pieces of the lasered stone, even if those words are not specifically noted in the descriptor of the code.Unlike CPT codes 52353 and 52332, there is no exclusionary parenthetical for 52356 that excludes reporting 52352, which leaves an opening to potentially allow ureteroscopy with stone extraction of a different or unrelated stone.

CPT guidelines address this issue as well. The following is from the CPT introduction to assist in the appropriate use of CPT codes (emphasis added in bold):

Instructions, typically included as parenthetical notes with selected codes, indicate that a code should not be reported with another code or codes. These instructions are intended to prevent errors of significant probability and are not all inclusive. For example, the code with such instructions may be a component of another code and therefore it would be incorrect to report both codes even when the component service is performed. These instructions are not intended as a listing of all possible code combinations that should not be reported, nor do they indicate all possible code combinations that are appropriately reported. When reporting codes for services provided, it is important to assure the accuracy and quality of coding through verification of the intent of the code by use of the related guidelines, parenthetical instructions, and coding resources, including CPT Assistant and other publications resulting from collaborative efforts of the American Medical Association with the medical specialty societies (ie, Clinical Examples in Radiology).¹

As noted above, CPT intended to include all required services to complete any procedure. Just as no code includes opening or closing a wound in the description, it is clearly implied that any service requiring opening or closing of an operative site should not be reported separately, even though CPT codes exist for these services. Therefore, it would not be appropriate or good care to leave stone fragments after laser treatment of the stone unless those fragments are small and will likely pass on their own or the physician plans to re-treat the stones later.

Finally, we consider the following excerpts from the definitions of a global period from the Medicare Claims Processing Manual, Definition of Global Surgical Package: Chapter 12 40.1.A. Components of a Global Surgical Pkg: Chapter 12 B3-15011

The Medicare-approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery.

• IntraoperativeServices: Intraoperative services that are normally a usual and necessary part of a surgical procedure²;

Based on CPT definitions, RVS Update Committee valuation, and Medicare rules, removing stone fragments from laser lithotripsy removed by flushing or basket abstraction would be included. Again, if the efforts required were unusual and greater than that which is typical, it could warrant the use of modifier -22. Also, we would point out that a separate stone (not a fragment of the treated stone) may be reported separately. Still, documentation must support the existence and treatment of a separate stone.

REFERENCES

1.CPT 2024: Professional Edition, page XV

2. Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners. Centers for Medicare & Medicaid Services. March 7, 2024. Accessed June 5, 2024. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

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.