Papillotomy billing: Two pathways to choose

I have a coding question that I just cannot find an answer for. The physician stated he did a papillotomy of kidney stones, and I’m not able to find a code for it.

The operative report indicated that physician obtained a flexible ureteroscope and did a renoscopy. The patient was noted to have intraparenchymal calculi throughout the lower middle upper pole and a posteriorly located lower pole. Capsulotomy was started on the lower pole calices, and multiple stones were released during the process. “We then addressed the middle pole calices and performed papillotomy throughout the middle pole,” the report said. “Finally, we performed papillotomies in the upper pole in standard fashion. Multiple renal calculi were extracted during that process. We then obtained a 1.9 caliceal basket and extracted all loose calculi.”

I asked exactly how the papillotomy was performed. He stated that he went up to the kidney with the scope. Once stones were identified, he lasered/cut the kidney to extract the stone. He also left the slit open to drain. Then once he got to the stones, he took them out with a basket. Please help.

Good question. Unfortunately, as you suggested, there is no code that specifically describes the procedure performed. In reading the operative note above, it appears that the capsulotomy and papillotomy were used to free stones. We agree that the procedure note clearly indicates a significant amount of extra work from that which is normally performed during a basket extraction of a stone or stones. Accordingly, we see two pathways, neither of which will sidestep the need for a manual review prior to payment.

Pathway 1: You might consider adding the –22 modifier to code 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]). Argue that the procedure required a significant increased effort and was more risky due the approach to the stones. You may wish to create an addendum to the operative note indicating the amount of time spent to accomplish the procedure and provide a relative reference to a standard stone extraction (ie, “The operation took 1 hour; 133% of the time required to perform a typical stone extraction.”). Future operative notes of this type should also include a relative time reference. If an indwelling stent is left, also report 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [eg, Gibbons or double-J type]).

NEXT: Pathway 2 - unlisted code 53899

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Pathway 2: Use an unlisted code 53899 (Unlisted procedure, urinary system) with guidance for the payer on how to pay for the service as an additional note to the payer in the form of a letter. We would recommend that you reference codes 52352 and 52346 (Cystourethroscopy with ureteroscopy; with treatment of intra-renal stricture [eg, balloon dilation, laser, electrocautery, and incision]) as a combined value upon which to base the reimbursement.

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Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at UT@advanstar.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.

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