When a patient has more than one stone in one kidney (multiple stones), or stones in both kidneys or ureters (bilateral stones), the urologist can gain more reimbursement and avoid fraud by coding based on the type of removal performed.
Different types of stone removals are outlined below with the correct coding solutions.
Removal by Lithotripsy
Code removal by extracorporeal shock wave lithotripsy (ESWL) with 50590 (lithotripsy, extracorporeal shock wave). The urologist can often ethically gain more reimbursement for treating multiple and/or bilateral stones.
- Multiple Stones. The urologist performs ESWL to break up a kidney stone. But neither the technique nor the code allows the urologist to target just one stone, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services in Denver. The ESWL procedure is the same regardless of the number of stones in the kidney, so there is no justification for billing extra for multiple stones. Whether the stones are in the renal pelvis, the calyx, the ureteropelvic junction, the ureter, or all four locations, use 50590 only once per kidney. The code is valued at a high rate because it is intended to cover those occasions when multiple stones are treated as well.
- Staged Treatment. Most urologists would treat bilateral stones with ESWL at different times one within the global period of the first ” says Michael A. Ferragamo MD assistant clinical professor of urology at the State University of New York at Stonybrook. “So they would need to indicate in the preoperative note that the ESWL will be staged with one kidney initially and another several weeks later.” Append modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to the second 50590 if done at a different time.
Note: When a patient has stones in both kidneys some urologists may treat both with ESWL at the same time although this is unlikely. Report 50590 with modifier -50 (bilateral procedure) in this case.
Use -LT and -RT modifiers to indicate on which kidney the 50590 is per-formed. If the left kidney stone is treated first use 50590-LT; for the second ESWL use 50590-RT-58.
Sometimes stones are treated more than once. For example the left kidney is treated in July and again in August and the right is treated in September. Code 50590 -LT for July 50590-LT-58 for August and 50590-RT-58 for September.
Removal by Ureteroscopy
Removal by ureteroscopy is coded 52320 52325 52330 52352 or 52353. Only ureteroscopy codes 52353 (cystourethroscopy with ureteroscopy and/or pyeloscopy; with lithotripsy [ureteral catheterization is included]) and 52354 (… with biopsy and/or fulgration of lesion) can be billed bilaterally says Cynthia Jackson RRA CPC coding specialist for Emory University Urology Group in Atlanta. “It is appropriate to bill these with a -50 modifier ” she says. When performing ureteroscopic stone removals sequentially do not use modifier -58 because ureteroscopies have zero-day global periods.
- Cysto with stone removal. When performing stone removal under fluoroscopy without a ureteroscope bill for multiple stones in one ureter by appending modifier -22 (unusual procedural services) to 52320 (cystourethroscopy [including ureteral catheterization]; with removal of ureteral calculus). Include the operative report and a short note explaining why the extra stones took more work.
Use layman’s terms in the note because it’s unlikely that a medical person will be the first to see your claim. For example note excessive bleeding the number of stones removed and most important how much longer than usual it took to perform the procedure.
“If it normally takes you half an hour to do 52320 and it took 1 hours due to the multiplicity of stones indicate that time at the top of your note to the carrier ” Ferragamo says. “Explain exactly why it took you so much time.” Because of the delay in payment and frequent denials of increased payment some urologists choose not to bill modifier -22 for removing two or three stones from the same ureter unless a lot of time is spent on the procedure.
If the urologist removes stones from both ureters at the same session use 52320-50.
- Cysto with stone removal or manipulation. When the urologist must either remove or manipulate stones ureteroscopically use 52352 (cystourethroscopy with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus [ureteral catheterization is included]). If there are multiple stones in one kidney append modifier -22 and file the claim on paper with an operative report.
Medicare will not allow modifier -50 on 52352. The dollar value of the code includes the occasional time that the procedure is performed bilaterally.
If one stone requires manipulation and another requires removal you may append modifier -22 to 52352. You cannot bill for the procedures separately because Medicare does not allow bilateral billing on 52352.
Ferragamo does not recommend adding modifier -22 for every case in which multiple stones are treated. “Only use modifier -22 if the work performed is significantly increased.” Medicare expects modifier -22 to be used in less than 5 percent of cases Ferragamo says adding that greater use increases the chances of an audit. If you specialize in difficult cases your use of modifier -22 will likely exceed 5 percent.
- Cysto with lithotripsy. When performing a combination of lithotripsy and ureteroscopy bill 52353. If there are multiple stones in one ureter append modifier -22 and include the operative note.
When performing 52353 in both kidneys append modifier -50.
Medicare will not allow 52351 (cystourethroscopy with ureteroscopy and/or pyeloscopy; diagnostic) to be billed bilaterally says Morgan Hause CPC CCS-P coding specialist with Urology of Indiana an 18-provider group in Indianapolis. This is likely due to the valuation of the code at a rate that would include both ureters and/or kidneys. Because it’s diagnostic it is more frequently performed bilaterally than the therapeutic ureteroscopy procedures.
Appending the Modifiers: -50 LT/RT and -59
Most coders prefer to use modifier -50 instead of modifiers -LT and -RT for Medicare because it allows one-line billing for bilateral procedures. While a urologist may like identifying which ureter he or she is performing a procedure on the coder can replace the -LT and -RT modifiers with modifier -50 and adjust the fee to 150 percent.
But under certain circumstances it is appropriate to use modifiers -LT and -RT rather than modifier -50.
“Using -LT and -RT helps the payer understand why you need bilateral payment ” says Jules Geltzeiler MD who practices with Shore Urology in Long Branch N.J. For example the patient has stones in each ureter that need to be pushed back into the kidneys with ESWL procedures anticipated in the future. Bill 52330-LT and 52330-RT linking 592.1 (calculus of kidney and ureter; calculus of ureter) to each. “Then you insert the permanent stents ” Geltzeiler says. ” Code 52332 -LT-51 (cystourethroscopy with insertion of indwelling ureteral stent [e.g Gibbons on double-J type]; -multiple procedures) and 52332-RT-51 if the payer is an HMO and 52332-LT-59 ( … distinct procedural service) and 52332-RT-59 if the payer is Medicare.”
Despite this coding scenario you may have to appeal if the payer doesn’t understand that two separate problems were handled with the two ureteroscopies and two stents. (For more on stents and modifiers see reader question on page 70.)
In another example the urologist performs a cysto with lithotripsy in the left ureter (52353) and a diagnostic ureteroscopy (52351) on the right ureter. Use 52353-LT and 52351-59. Appending modifier -59 pulls 52351 out of the bundling edits. Also bear in mind that CPT states that surgical cystourethro-scopy includes diagnostic urethroscopy. Since Medicare does not allow bilateral billing for 52351 the use of -LT and -RT modifiers is inappropriate as is the use of modifier -50.
Note: If the carrier computer system assumes that 52351 is bilateral and throws out the second listing of the code you should appeal explaining that two different procedures were performed.
Coding Bladder Stones
Bladder stones cannot be billed bilaterally. The bladder stone fragmentation codes — 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 (… complicated or large [over 2.5 cm]) — are unilateral only. For fragmentation of multiple stones use 52318. Neither code allows modifier -50. The bladder cannot be a bilateral organ.”