Question: My urologist performed a cystoscopy, transurethral incision of an orthotopic ureterocele, ureteroscopy, and a double J stent placement. I have drawn a blank on how to report the ureterocele incision. Here is the doctor’s note: “A 24 resectoscope was introduced without any difficulty. Subsequently I went ahead and then used the Collin knife on the resectoscope and using pure cutting, I went ahead and made two incisions in the distal ureter laterally and inferior almost at the level of the floor of the bladder in the lateral and the medial aspect of the ureteral opening. The ureterocele opened up nicely. The flap of the tissue was raised up and this appeared to collapse well.” How should I report this?
Answer: For this scenario, you should report the following codes:
- 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic) for the cystourethroscopy and ureteroscopy
- 52300 (Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral) for the ureterocele treatment
- 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) for the stent placement.
Remember: Some payers will require that you add modifier 51 (Multiple procedures) to both 52300 and 52332. Modifier 51 is an informational modifier to alert payers that you have performed multiple procedures. In other words, the modifier indicates that the multiple procedure payment reduction should apply.
Although Medicare and other payers once required modifier 51 when you performed multiple procedures, that’s not the case anymore. In fact, many Medicare payers will reject a claim with modifier 51, according to experts. However, some Medicaid payers still require the modifier. Follow payer instruction to decide whether to use this modifier.