How to code for cystoscopy with litholapaxy of more than 40 bladder calculi

There are 2 codes available to report cystoscopy with litholapaxy of bladder calculi: CPT code 52317 (less than 2.5 cm) and CPT code 52318 (greater than 2.5 cm). There are also 2 codes for stone or foreign body removal (without litholapaxy): CPT codes 52310 (simple) and 52315 (complex)…Some of my colleagues and I disagree on the proper coding for a case in which a patient undergoes cystoscopy with litholapaxy of more than 40 bladder calculi measuring 1 mm to 6 mm each. Some of us believe that the size in millimeters of each of the 40 calculi should be summed together and therefore reported with CPT code 52318. However, one of my colleagues [believes that] CPT code 52318 should be reported because of the complexity of the multiple stones. Yet another coworker says that the stones should not be summed, and that it is most appropriate to report CPT code 52317 with modifier –22 (prolonged services) added to reflect the extended time. What are your thoughts?

Jonathan Rubenstein, MD

As with most cases, we need to start with a review of the documentation. You have indicated that litholapaxy of more than 40 calculi measuring 1 mm to 6 mm eachwas performed. Based on this information, we consider the options that you have correctly identified: 52317 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small [less than 2.5 cm]), and 52318 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large [greater than 2.5 cm]).

The variation in the 2 codes relates to the final portion of the code after the semicolon, “simple or small (less than 2.5 cm)” vs “complicated or large (greater than 2.5 cm).” The use of the word “or” between the descriptive (simple vs complicated) and the size-based verbiage (small [less than 2.5 cm] vs large [greater than 2.5 cm]), allow the selection of code on either size or complexity of the service. The fact that description refers to a single stone (calculus) and does not reference multiple stones (calculi) makes the decision more complex. We note that the medically unlikely edit (MUE) for both codes is 1 with an adjudication indicator (AJI) of 3, indicating that the MUE is based on common clinical performance. The MUE of 1 directs the computer that is processing the claim to deny more than 1 unit for each code on the same date

Mark Painter

of service. Although the AJI does allow for an increase of units with appropriate documentation, it would appear that Medicare’s interpretation of the CPT code does not consider the reporting of multiple stones appropriate as additional units listed for the code. Further, there is no guidance within the CPT description for multiple stones, unlike codes for bladder tumor(s) for codes 52234 to 52240.

With this lack of guidance on size-based billing for multiple codes, we turn to the more descriptive-based language of simple vs complex in the code. If we look at the intent of the simple or small as being the correct code for the treatment of a single smaller stone, it is hard to argue that the treatment of 40 small stones during the same session is not complex in comparison. Therefore, we would recommend the use of code 52318 based on the complexity of removing 40 small stones during the same operative session and for coding in this case the size of the stones, although documentationdoes factor into the code selection.

With regard to the use of modifier –22 (Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier – 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work [ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required]. Note: This modifier should not be appended to an evaluation/management service.) We would not recommend using modifier –22 with code 52317 as the modifier is used to indicate increased complexity and CPT code 52318 describes a complex litholapaxy regardless of size. However, the modifier –22 could be appended to code 52318 if the documentation supported that the effort required to perform the complicated treatment of the stones for a patient was substantially greater than typically required. With the information you have provided, it is not possible for us to recommend the addition of –22 to code 52318. If the documentation supported the use of modifier –22, it should be appended.

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.