Same-side shock wave lithotripsy, URS present coding questions

Jonathan Rubenstein, MD

I’m looking for some guidance on a couple of stone case scenarios. Both scenarios have to do with shock wave lithotripsy (SWL) and ureteroscopy with laser lithotripsy being performed on the same side during the same operative session.

First scenario: A patient has stones in both the kidney and ureter on the right side. The physician has both ureteroscopy with laser equipment and an SWL machine available. The urologist performs a ureteroscopy with lithotripsy of both the ureter and kidney stones and places a stent, completely lasering the ureter stone but incompletely lasering the kidney stone.The provider made an intra-operative decision to perform SWL of the remainder of the kidney stone to complete the procedure.We were planning on submitted Current Procedural Terminology (CPT) code 52356 –59/XU, RT using ICD-10 N20.1 for the ureter stone, and then also CPT code 50590 – RT with ICD-10 code N20.0 for the kidney stone. Is this the correct way to code or is there another way?

Mark Painter

Second scenario:The patient has a stone in the right kidney. The physician starts treating the stone with SWL. However, during the procedure, the physician notices that the stone is not breaking and makes an intraoperative decision to stop the SWL and to perform ureteroscopy with laser lithotripsy. The stone was then successfully treated and a stent was placed. Can we bill for both CPT codes 50590 and 52356, or do we need to report only what has completed the operation?

Excellent questions. For scenario 1, the provider is treating 2 separate and identifiable stones in separate anatomic locations ultimately treated with 2 different modalities (ureteroscopy with laser lithotripsy and SWL). CPT code 52356 describes “Cystourethroscopy with lithotripsy including insertion of indwelling ureter stent (eg, Gibbons or double-J type).” There is a parenthetical on this code that informs the provider to not report CPT code 52352 (cystoscopy with stent placement) or CPT code 52353 with CPT code 52356 when performed on the same side. CPT code 50590 “lithotripsy, extracorporeal shock wave” is not excluded by the parenthetical.We agree with the codes you chose.

Scenario 2 is a bit more challenging as there is just one stone. On one hand there is different work and approaches of CPT codes 50590 and 52356, so one would reasonably conclude that reporting both CPT code 50590 (appended with modifier –52 for reduced service) along with CPT code 52356 is the best and most accurate coding, which would be the best approach for non-Medicare insurers.Medicare however follows the National Correct Coding Initiative (NCCI) Edits Policy Manual which states that multiple methods of performing a procedure cannot be performed at the same patient encounter and that if an initial approach fails and is followed by an alternative approach, only the completed or last uncompleted approach may be reported.Therefore, only CPT code 52356 should be reported for Medicare beneficiaries.

For both scenarios it is important to follow the insurer guidelines for that patient. And as always, accurate documentation is important to be able to support the codes chosen.

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