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Tanesha Posted Thu 16th of November, 2017 00:09:07 AM
The pt. had a stent placed for a ureter stenosis (52332), but a bladder tumor was resected as well after the stent placement. Excerpt from op report. A 21-French rigid cystoscope was inserted into the urethra. The urethra was normal. The prostate had some mild lateral lobar hyperplasia with a small median lobe. He did have moderate trabeculation of the bladder. His right ureteral orifice was displaced somewhat laterally due to his previous bladder tumor resection which encompassed the right ureteral orifice. At this point, I then placed a 5-French open-ended catheter into the right ureteral orifice. The right UO was slightly stenotic. A retrograde pyelogram was performed which did show mild to moderate hydronephrosis. In the distal ureter, the ureter did taper towards the proximal ureter, but there was still some mild dilation of the collecting system....A wire was placed into the kidney, there was still some residual contrast in the upper pole collecting system. I then placed a 24 cm x 6-French double- J stent over a wire. Once the distal aspect of the stent was at the bladder neck, the wire was removed, the stent was deployed. Can I unbundle 52235 and code the stent as well as the pt. had stenosis?
SuperCoder Answered Fri 17th of November, 2017 06:19:51 AM

According to the op-report, it is correct to bill CPT 52332 for the stent, and CPT 52235 for tumor resection for the medium bladder tumor with size 2.0 to 5.0 cm (when performed with stent placement). As per CCI edit guidelines, the procedures cannot be fully unbundled, code 52332 is a column 2 code for 52235, but modifier 59 is allowed in order to differentiate between the services provided. Hence, when billing both the codes together, then append modifier 59 with CPT 52332.

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