Coding Q&A: How to bill for second-generation stone device

Regarding your recent article, “Reporting use of ureter access sheath with suction component,”¹ what about using the new second-generation Calyxo CVAC system? The company has told us this can be cross-walked to 52001 for additional work relative value units (RVUs) because this is a steerable aspiration device. Is this appropriate?

Jonathan Rubenstein, MD

First, we will clarify that when answering this question, we are addressing the physician billing of the treatment of stones using any device that includes aspiration capabilities to remove stones and stone debris in conjunction with laser lithotripsy with or without inserting a stent. Billing for the device(s) used is the facility’s responsibility, yet it is dependent upon the physician’s work (and supplies). (Billing for the device by the facility under code C9761 has been discussed previously and will require an understanding of payer guidelines and interpretation of this code based on the device used. Although we will not update the facility billing in this article, we note that payer policies may have changed since the publication of our previous article. We encourage facility billers to monitor payer bulletins and policies for current requirements.)

Mark Painter

To answer the question about whether an additional Current Procedural Terminology (CPT) code can be used for stone irrigation and aspiration, we need to consider the evolution of stone aspiration technology and the physician effort required to perform the service. The first generation of the Calyxo device was a separate steerable aspiration catheter inserted into the kidney, typically after the performance of flexible ureteroscopy with laser lithotripsy to break the stones into small enough particles to be aspirated. For this procedure, after the stone was adequately treated, the ureteroscope was removed, and then the separate steerable aspiration catheter was inserted to remove stone remnants and debris. One could argue that inserting a unique aspiration catheter is additional work above and beyond that of the surgical procedure and equipment typically used to complete the procedure. There was/is no existing CPT code for aspiration of stone debris from the kidney. An alternative to aspiration is the stone basketing for removal of lasered stone fragments that has traditionally been considered inherent to CPT codes 52353 and 52356, which was/is of concern when considering the use of additional codes.

So, what about stone aspiration? However, based on the additional work effort for using a separate aspiration catheter, we and others have recommended reporting the unlisted code CPT code 53899 as there is no specific code to describe this additional work. CPT code 52001 has also been recommended for consideration in reporting this work or as a comparison code for the unlisted code. It is one of a few existing CPT codes that at least closely reflect the work effort required for aspiration. As we all know, unlisted codes are not valued but reimbursed by the payer under instructions from Medicare or the contract. The most common method of assigning work, charges, and reimbursement for an unlisted procedure is to compare the work effort to an existing code. The actual charge and work assignment should be relative and may not be exact, with supporting documentation describing the variable work performed as either greater or less than the comparison service. Note: The facility, either an ambulatory surgical center or hospital outpatient department, is not typically reimbursed separately under facility payment structures when an unlisted code is used.

The second generation of the Calyxo device and other devices on the market have an integrated aspiration channel within their device (ureteroscope or sheath) and no longer require the use of 2 different devices to complete the procedure. Accordingly, intraoperative service times and work effort have decreased compared with using separate devices. When we consider the global package in general, we note that the completion of the procedure performed includes the work efforts relative to a standard case returning the operative field to a safe condition, which includes cleaning the operative field, repairing bleeding if necessary, and closure if necessary. Reporting of separate services with additional CPT codes requires clear and separate work efforts that are medically necessary. With stones in particular, we note that basket retrieval of stone debris treated with laser is considered included and not separately reported. If, however, separately diagnosed stones are removed by means other than lithotripsy, the services are generally considered billable. The same global principles should be applied to the use of aspiration devices that do not require a separate procedure (ie, a separate scope to be inserted).

Considering the work and the global concept, it would be more appropriate to report the proper CPT code for laser treatment of the stone (52353: cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included] or 52356: cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double-J type])for the stone treatment and aspiration. If the time and work effort supported by the documentation warrant, a modifier -22 should be appended to the CPT code. We will note here that we have spoken with physicians who have reported operative times and work using these new devices that would not support the use of modifier -22 or the unlisted codes.

It should also be noted that a payer may require that the unlisted code be reported in addition to the primary CPT code to support reporting of the appropriate facility codes for these devices.

Regarding work relative value unit (RVU) measurement for internal remuneration, different options are available for the extra work, if required, for the use of the aspiration device. Some groups have agreed to the work RVU increase based on 52001, even if the code is not reported. Other groups have agreed to a percent increase to the work RVU based on the use of modifier -22 for this and other procedures performed.

REFERENCE

1. Rubenstein J, Painter M. Reporting use of ureter access sheath with suction component. Urology Times. July 5, 2024. Accessed April 7, 2025. https://www.urologytimes.com/view/reporting-use-of-ureter-access-sheath-with-suction-component

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

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.