Urology Don't Get Litho-Tripped Up by ESWL Coding

Proper modifier use is key to surviving these kidney stone scenarios

ESWL is ESWL is ESWL right? Wrong. Multiple stones in each kidney fragmented stones and stent placements are just a few of the things that can complicate coding for extracorporeal shockwave lithotripsy (ESWL).

ESWL represented by 50590 (Lithotripsy extracorporeal shock wave) is one of the most frequently performed procedures in urology practices as well as a popular and effective treatment for renal calculus (kidney stones). Our experts give you the facts for seven tricky ESWL coding scenarios.

Scenario 1: Multiple Stones in 1 Kidney

Problem: The urologist performs ESWL to break up multiple stones in the same kidney. Can you bill CPT code 50590 for each stone the urologist fragments?

Solution: Sorry – if there are several stones in one kidney you cannot charge 50590 more than once for that session says Carolyn Zell CPC billing manager for the Urology Team in Austin Texas.

Scenario 2: Stones in Right Kidney and Right Ureter

Problem: The urologist finds stones in both the right kidney and the right ureter. Can you bill for ESWL performed on both sites?

Solution: 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 for each session. The code is valued to cover those occasions when multiple stones are treated as well.

Scenario 3: Stones in Both Kidneys

Problem: Most urologists would treat bilateral stones with ESWL at different times one within the global period of the first. How can they get reimbursed for both procedures?

Solution: Usually when faced with bilateral kidney stones urologists will indicate in the preoperative note that the ESWL will be staged with one kidney initially and another several weeks later. This prospective planning for a staged procedure must be clearly documented in the preoperative note the patient’s chart or the operative note of the first procedure.

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 says Lisa Center CPC quality review coordinator for the Freeman Health Center in Joplin Kan.

Note: When a patient has stones in both kidneys some urologists may treat both with ESWL at the same time although this is “rare ” Center says. Report 50590 with modifier -50 (Bilateral procedure) in this case.

Remember: Use -LT (Left) and -RT (Right) modifiers to indicate which kidney the ESWL targeted Center says. If the left kidney stone is treated first use 50590-LT; for the second ESWL use 50590-RT-58.

Scenario 4: ESWL Followed by Stent Placement

Problem: Three days after an ESWL a patient returns for a stone obstructing the ureter. In the operating room the urologist places a stent. Code 50590 has a 90-day global period so the postoperative stent placement would normally be included in the fee for 50590. Can you code for the stent placement?

Solution: Medicare views the need for a stent such as a stone obstructing the ureter as a complication so you should append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to 52332 (Cystourethroscopy with insertion of indwelling ureteral stent [e.g. Gibbons or double-J type]) says Karen Delebreau coding specialist with Urological Surgeons in Green Bay Wis.

For commercial and private carriers bill the treatment of this scenario exactly the same appending modifier -78 to the second procedure code. However some private payers might view this as a new problem and therefore require you to append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to 52332.

Remember: Medicare will not pay for any postsurgical complications treated out of the operating room in locations such as your office the emergency department at the bedside or in a treatment room in the hospital.

Scenario 5: Recurring Stones Post-ESWL

Problem: A patient with another stone presents within the global postoperative period of a previous ESWL. Since it’s a new stone the urologist did not write in the preoperative note for the first ESWL that a second ESWL would be staged. How should you report this procedure?

Solution: If the second ESWL is for a different stone in the same kidney and done within the postoperative period of the first ESWL Center advises using modifier -79 (Unrelated procedure) to indicate an unrelated procedure. “It’s unrelated to the first surgery” Center says. “Even though it’s the same procedure it’s a different stone.”

Kidney stones do tend to recur most often within months or years after an ESWL treatment. If a urologist performs another ESWL on a patient after the global period for the previous one has expired report code 50590 without modifiers Center says.

Scenario 6: ESWL Followed by More Extensive Procedure

Problem: The urologist performs an ESWL for a renal pelvic stone. After one month the physician realizes the stone was incompletely fragmented by the ESWL and decides to perform 50081 (Percutaneous nephrostolithotomy or pyelostolithotomy with or without dilation endoscopy lithotripsy stenting or basket extraction; over 2 cm). The diagnosis for both procedures is 592.0 (Calculus of kidney).

Solution: When a procedure is performed in a global period for the same diagnosis as was linked to the initial procedure – and the second procedure was not planned or staged at the time of the initial procedure – the second procedure must be more extensive than the original procedure to be separately billable. The coder should bill 50081 with modifier -58 appended. This will bring full payment for 50081 but a new 90-day global period would begin.

In this particular clinical scenario modifier -58 is used on a more invasive second procedure during the 90-day global period of the first unsuccessful surgery. This procedure was not prospectively planned or staged and documentation of this fact is not necessary as was needed in Scenario # 3 above.

However: This is a good scenario to bounce off your carriers Delebreau says. “If it’s group insurance and it’s the same stone I usually don’t hesitate to use a -58 because it’s related ” she says. She had heard different advice about Medicare though so she investigated.

“I checked with some representatives and I explained situations like this where they’re going back to re-treat the same stone ” she says “and I’ve been told that I could still use the -58 as long as it’s the same stone.”

Scenario 7: Stone Moved Back Into Kidney Before ESWL

Problem: Using cystourethroscopy and a ureteral catheter a urologist displaces a stone out of the ureter and back into the kidney with plans to perform ESWL on the stone later. How should you code both procedures?

Solution: For the first procedure in which the stone is moved into the kidney use 52330 (Cystourethroscopy [including ureteral catheterization]; with manipulation without removal of ureteral calculus) Center says. “After the cysto and stone manipulation into the renal pelvis using the ureteral catheter the doctor would take the patient over to the ESWL machine ” she says.

Since 52330 is bundled into code 50590 bill 50590 for the ESWL and 52330 for the stone manipulation with modifier -59 (Distinct procedural service). Modifier 59 indicates that the stone manipulation was performed earlier in the day at a previous separate encounter.