How to bill for bladder stone removal performed during cystoscopy

How is the following scenario best coded? A provider performed a cystoscopy, sees a bladder stone, and inserts a stone basket through the cystoscopy to grab and remove the stone. Would this best be coded with CPT code(s) 52310 and 52315 or CPT code(s) 52317 and 52318?

Jonathan Rubenstein, MD

Let us look at the 4 CPT codes that have been proposed to describe this situation:

• 52310: Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple

• 52315: Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated

• 52317: Litholapaxy; crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (< 2.5 cm)

• 52318: Litholapaxy; crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (> 2.5 cm)

Mark Painter

Lithopaxy (CPT codes 52317 and 52318) is the process of crushing and/or breaking the stone to a size small enough to remove. In the case described, the stone was broken to be removed but rather was small enough to grab with a grasper for removal, therefore one should not report CPT 52317 or 52318. 

When it comes down to the 2 foreign body, calculus, or stent removal CPT codes, we need to look a bit deeper. CPT code 52310 describes the work of a simple removal of bladder stones or a bladder foreign body, whereas CPT code 52315 is for a complex procedure. So, what makes a procedure simple or complex? That is a great question. When looking at the description of work, a simple removal can include reintroduction of the cystoscope multiple times until all stents, stones, or foreign bodies are removed. The complicated procedure is described as the removal of an encrusted stent, for which twisting and/or torqueing movements are needed to try and dislodge some of the encrusted material from the stent, or needing to irrigate the bladder until all the stone material has been removed. Therefore, in the case described, it seems that this stone was rather easily removed. CPT 52310 seems most appropriate. 

What code should we report when performing a urine analysis dipstick when the urine is obtained not by spontaneous void but rather by catheterizing (in-and-out) the patient’s bladder? The insurer is Medicare. I know there is a CPT code 51701 for catheter insertion, but we were told to report P9612, but there was no work relative value unit (RVU).

CPT code 51701 describes “insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine)” and would be the code typically used to report such a service. However, you can see within the parentheses that this code describes the typical use, which is to check residual urine. Medicare uses Healthcare Common Procedure Coding System (HCPCS) code P9612 (catheterization for collection of specimen, single patient, all places of service). This code should be used for Medicare patients when urine is obtained by straight catheter and sent for a study such as a urine analysis or urine culture. P9612 is an HCPCS Level II code developed and administered by CMS. HCPCS Level II codes are grouped into specific categories and are used to supplement the CPT coding system. Codes that begin with a P are considered pathology codes and are typically reimbursed under the Clinical Laboratory Fee Schedule. P9612 is no exception. Reimbursements under the Medicare Clinical Laboratory Fee Schedule are assigned a fee for each service instead of RVUs that are converted to fees using a Geographic Adjustment Factor and a Conversion Factor. If you research the fee schedule or look up the fee for P9612 in AUA (American Urological Association) CodingToday or on the Medicare website, you will see a fee of $3.00 for code P9612. In short, it is reimbursed, but minimally.

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.