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    Coding Q and A

    Q. What is the modifier for retrogrades and renal stents placed in the office under fluoroscopy and local anesthesia? What are the codes we should use?

    A. First and foremost, for procedures performed in the office, you would use "office" as the place of service, and you would charge the non-facility fee on the fee schedule. For example, the national Medicare average payment for the non-facility fee for the insertion of the stent is $332.74, while the facility fee is $155.

    If the physician performs a diagnostic retrograde (52005) and the insertion of a stent (52332) at the same setting, each should be billed separately. No modifier is needed for Medicare because the two are not bundled. However, if you were billing this to a patient with private insurance, I would apply the-51 modifier to the retrograde, which is the lesser of the two procedures. If a physician reads the retrograde in the office and does not send it out to a radiologist for additional reading, then the physician would also charge the radiographic reading: 74420, urography, retrograde, with or without KUB.

    Because the physician owns the equipment and is reading the X-ray, charge it without a modifier. Code 74420 without a modifier pays both for the technical (-TC) and the professional fees (-26).

    The fluoroscopy, unfortunately, is bundled into the other codes. If the fluoroscopy is used to facilitate the procedure, then it should not be charged.

    Charge for the fluoroscopy only if the fluoroscopy is being conducted for a separate reason. For example, if the physician performed a retrograde and the insertion of the stent on the right kidney and he used the fluoroscopy to evaluate the left kidney for stones, then you would charge fluoroscopy and would pull it out of the bundle by using the modifier-LT for the fluoroscopy and-RT for each of the other procedures.

    If the patient was originally scheduled for the insertion of the renal stent and the retrograde was performed to facilitate the insertion of the stent, then you would charge only for the stent insertion.

    Q. Is the code 52000 listed as a surgical procedure or a scope code?

    A. All codes, including the 10000 series of CPT codes through the 60000 series of procedural codes, are considered surgical procedure codes. That includes all of our 50000 series of urologic codes. Within the surgical procedural codes are codes that are considered endoscopy codes. You will find endoscopy codes under the GI, orthopedic, respiratory, cardiovascular, and GU sections. Cystoscopy (52000) is an endoscopy code. In fact, it is considered the base code for many urologic endoscopy procedures.

    I recommend that you visit the AUA Coding Today Web site ( http://www.auacodingtoday.com/) and click on "52000." Under the CPT/HCPCS tab, click on the small tab "national," and you will be given a list of codes considered to be in the same family.

    In this case, most of the codes are bundled with a cystoscopy, and cystoscopy cannot be charged separately. However, if you bill any of the other two codes in that family, the second procedure will be paid according to the multiple endoscopy rules. The difference between payment for the procedure performed and the base code will be paid, as opposed to the normal procedural reductions, e.g., 50%.

    Q. How do you bill for a cystoscopy, laser lithotripsy of bladder stone, and endoscopy of ureteral intestinal segment with removal of multiple stones when the patient has had a transplant, including a segment of small bowel replacing the distal ureter?

    A. This situation presents a very interesting problem with coding. First, a 52318-litholapaxy—crushing or fragmentation of calculus by any means in bladder and removal of fragments complicated or large (over 2.5 cm)—was performed and should be charged.

    An endoscopy through a stoma from the bladder into the small intestine was performed, which could be partially coded as 44380, ileoscopy, through stoma, diagnostic, with or without collection of specimens by brushings or washings. Unfortunately, there is no comparable code for removing a foreign body through the ileoscopy. I would suggest using 52320, cystoscopy with removal of ureteral calculus, as your second code.

    In this case, the stoma is from the small bowel to the bladder and the bowel is functioning as a ureter.

    Therefore, I think you are perfectly correct in using the code. As a bonus, 52320 pays a lot better than 44380.

    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...