Kellie Posted Wed 30th of October, 2019 09:30:09 AM
Would lithotripsy (ESWL) and stent placement be coded as 52356 or would 50590 and 52332 be appropriate? Here is the report:
Under adequate general anesthesia, the patient was placed in the
lithotomy position. He was prepped and draped in the usual sterile fashion. In a well-lubricated
urethra, the 21-French cystopanendoscopy was introduced. On panendoscopy, the bladder mucosa
was smooth without tumors or stones and both orifices were normal with clear efflux. The left
ureter was catheterized with a 0.038 Terumo guidewire to the level of the renal pelvis. Over this
guidewire, a 4.8 French 26 cm double-J stent was positioned fluoroscopically in the usual fashion.
The bladder was emptied and the cystoscope was removed.
The patient was then placed on the table in a supine position. A Dornier Delta machine was used.
Fluoroscopy was used to appropriately position the stone in the correct blast path (at the F2 position)
in the AP and oblique views. A total of 2500 shocks were delivered to the stone. The power ranged
from 1-5 bars. The fluoroscopy time was one minutes. Post film was not done. Thank you for your help and time!
SuperCoder Answered Thu 31st of October, 2019 08:53:10 AM
Thank you for your question.
As per the above provided documentation, appropriate code would be CPT® code 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent). This code includes all the major work performed in the above report, i.e. bladder and ureter examination, lithotripsy and stent placement.
Note: Reporting separately for lithotripsy and cystourethroscopy with stent placement will be inappropriate when a more comprehensive code is available.
Hope that helps!
Please feel free to write if you have any further question.