How to use CPT 52356 for removing multiple stones

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In one of my recent cases, there were three stones in three separate locations of the right kidney and one small stone on the left. I pulverized one with lithotripsy, then manipulated the second stone into position to perform lithotripsy on it. I then manipulated the third stone into position to perform lithotripsy on it. Following this, I flushed out the kidney thoroughly and could see no additional fragments. I inserted an indwelling stent on the right. I elected to insert a stent on the left side but did not perform any other procedures on the left. How do I code for that using the new code, 52356?

As with many cases, there are two answers to your question.

First, for charges to Medicare: Since there were three “non-contiguous” stones on the right, you should be able to charge for the primary procedure performed to remove each stone. However, according to the National Correct Coding Initiative, as stated in a recent letter to the AUA, you can no longer make separate charges to Medicare for the treatment of multiple stones on the same side. (We feel that the NCCI’s ruling overstepped its authority and is incorrect. The AUA is appealing the interpretation.)

You can charge separately for the stent insertion on the left. You would not be able to charge for any of the contributory procedures such as manipulation, flushing the kidney, fluoroscopy, or irrigation. Code 52356 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) includes the performance of lithotripsy and the insertion of the indwelling stent on the same side. In addition, one 52332 service (cystourethroscopy, with insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) was performed on the left side, so you would bill as follows:

• 52356–RT

• 52332–LT.

Second, non-Medicare and in our opinion the correct coding: CPT directions and the actual definition of modifier –59 provides that if documentation supports a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual (CPT 2014 modifier –59) may be reported using modifier –59. Your question supports that three separate stones, in three different sites, were treated during the same day by the same individual. As such, correct coding would indicate that the service should be reported to non-Medicare payers following CPT correct coding directives as:

• 52356–RT

• 52353–59

• 52353–59–76 (the –76 modifier alerts the payers that this is not a duplicate charge and may not be required by all payers)

• 52332–LT.

Next: Coding for post-TURBT mitomycin instillation

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National Correct Coding Initiative (CCI) edits appear to bundle 51720 when coded with 52234-52240 (transurethral resection of a bladder tumor). Our physicians frequently instill mitomycin after the resection for our day surgery patients. The American Hospital Association coding clinic for Healthcare Common Procedure Coding System indicates this is appropriate. But this doesn’t seem to meet the Medicare definition of separate site, lesion, injury, or encounter. Is modifier –59 appropriate?

You have noted correctly the bundling issues as they exist in the CCI. We feel that the use of the –59 is appropriate for these cases. The instillation of the mitomycin or another anticarcinogenic drug following a TURBT is provided to patients as ongoing treatment of the disease and not a part of the excision of the tumor per se, and you should be paid separately from that procedure.

We have also noted that many physicians wait to instill the anticarcinogenic drug until they are in the recovery room. If that’s the case, the different “encounter” definition has been met.

In either case, this is another instance where the CCI has pursued a payment policy that is inconsistent with treatment and/or proper coding in the interest of saving Medicare a few cents. Expect more of these bundling pairs to appear in the CCI. We would encourage each of you to write to the AUA or directly to CCI with clear reasoning as to why in fact code pairings like this should not be included in CCI.

With the number of issues faced by urology today with health care reform, implementation of ICD-10, code bundling, and value changes, the AUA has its hands full, and all urologists will need to get involved in changing the rules to help protect patient treatment. Get in the game; if you do not protest, you will be restricted.

I am a certified coder and a biller and have tried to tell my physician that you cannot charge for establishing a treatment on the same day for a patient on whom you have just performed a cystoscopy. My doctor tells me that he thinks you can and that he heard as much at one of your seminars.

It may not happen very often, but this time your physician is correct; if the E&M encounter following the cystoscopy was “significant, and separately identifiable,” it can be reported on the same date as a cysto. First, the visit must be “separate,” which means that it was more than a passing thought and more than what is required in standard follow-up for the cystoscopy. For ongoing treatment, that means it took time to explain to the patient the need and the reasoning and to establish the appropriate treatment based on the findings of the cystoscopy or findings from discussion with the patient. Discussing and/or treating the disease process is certainly “separately identifiable” from the routine global content of the cystoscopy.

Therefore, you have met the definition of the –25 modifier, which should be attached to the appropriate level and category of E&M service:

• 52000

• 992__ –25.

For example, for a cystoscopy (52000), level 4, established patient, the correct code would be 99214 –25.UT

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