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Marisela Posted Tue 05th of August, 2014 13:08:04 PM

We have encountered a situation where the physician is coding that he is doing a 'lithlopaxy' in office (523170); after thorough review of the code, we find that this procedure is done under general anesthesia.

His office procedure note reads: "with local anesthesia, flexible scope: bladder - normal, urethra - normal, prostate - normal, bladder stone - removed - crushed"

After discussing with the physician, he states the following: "No anesthesia was used; I used a grasper to pinch the stone, and it crumbled/disintegrated." I am unable to locate a code that would describe said procedure. Please advise.

SuperCoder Answered Tue 05th of August, 2014 17:14:06 PM

For this procedure you should use 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple) as he was not intending to crush the stone it crumbled or disintegrated.

52317 would be used when the physician crushes the stone using instrumentation so that the stone may be removed.

Hope this helps.

Marisela Posted Wed 06th of August, 2014 16:22:58 PM

Thank you so much1

SuperCoder Answered Wed 06th of August, 2014 16:45:36 PM

You are welcome.

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