Q.1. What code would you bill for an endoscopic removal of renal stent that has migrated down the ureter and coiled within an ileal conduit. What diagnosis would be correct?
Answer: If it's a renal stent, the urethral renal stent that has been displaced down the ureter and coiled within an ileal conduit. So that immediately becomes a foreign body in the conduit. Now, since the conduit is small bowel, it would be a foreign body in an intestine which would be small intestine. The diagnosis I would use for that would be a foreign body which would include a stone in the intestine either it's small or large bowel. And I would use the diagnosis 936.
For removal of that, you have two codes that you may want to use. One is the 52315 with modifier 52. The ileal conduit is the substitute bladder, and the AUA through the physician’s reimbursement services has reviewed this. And since this is a substitute bladder, you can use the bladder codes 52310 or 52315 adding modifier 52 indicating that I did removed something but I did not do a cystoscopy. So I would bill the 44380 which would be an ileoscopy or an endoscopic examination of the ileal conduit. And because this is a complicated removal of this foreign body which is the coiled up stent in the conduit, I would bill the 52315 with modifier 52.
Both of both and I would put the diagnosis for the 44380. See that's an intestinal segment. That's an intestinal evaluation. For the diagnosis for that code, I would put the foreign body in the intestine 936. Now, since you're using the 52315 which is a urological code but you're modifying it with the 52, you can still use a urological diagnosis. And I would use foreign body in the bladder because this is a substitute bladder. And that code would be 939.0 that I would use for the 52315 with modifier 52.
Q.2. How would you code for a superpubic cystotomy using an (unintelligible) urethral sound instead of a Lowsley retractor?
Answer: Many urogynecologists and urologists that do a lot of female urology procedures, when they finish the procedure which is usually done vaginally, they do not want to open up the abdomen but they want to put a superpubic tube in. So they put in instrument within the bladder such as a Van Buren Sound which is a regular male sound or the Lowsley retractor which has jaws that open and can pull something back into the bladder. What they do is when they put it in through the urethra, they depress it so that the end of the Lowsley retractor or the end of the Van Buren Sound, you can feel it through the abdominal wall as it brings the bladder up to the interior abdominal wall.
And with that Lowsley retractor or the Van Buren Sound, you make an incision, a short, a small incision down onto those instruments palpated through the abdominal wall. You can do this easily of course if the patient is thin. If the patient is rather heavy, then he may not be able to do this.
They cut through the skin. They cut through the subcutaneous material. They make an incision in the fascia, the anterior rectus fascia. They make an incision in the muscle, the recti muscles. And then they make an incision in the perivesical fascia and then through the bladder musculature itself. And then they pass the Van Buren Sound through this opening. And now, you have the sound or the Lowsley retractor.
The Lowsley retractor is used very often although you can use the Van Buren Sound and fit on the catheter. But the Lowsley retractor has jaws that now you open. I turn the handle. The jaws open. You put in a catheter within the jaws. Close the jaws. And then begin to pull out of the urethra the Lowsley retractor. And then you can blow up the balloon. Let go of the bag. And you have your superpubic tune draining the bladder and without having to make a big incision or a big abdominal incision.
You should still bill this as an open procedure because you've incised the muscle. You've incised the bladder. You've incised the skin. You’ve made an incision. It may not be as big as a formal open. But I would still bill this when you use a Van Buren Sound or the Lowsley retractor. I would bill this with the 51040.
If you happen to do a sling procedure for stress incontinence or an anterior repair or a pelvic reconstruction and you want to do a superpubic drainage, you may also some urologist, urogynecologist or gynecologist use the punch technique or a trocar cystotomy in which they make a little incision in the skin and then put this trocar into the bladder.You do this only if the bladder is distended and you can feel it above the pubic symphysis. And then you put in the catheter—that's a trocar cystotomy. You've only incised the skin or maybe a little of the subcue. That should be billed with the code we spoke about earlier, the 51102.
And that is also a code that is not bundled into the vaginal procedures or a sling procedure. And you will be paid for both of those. So to answer that question, it would be the same as when you use the Lowsley retractor. It would be 51040.
Q.3.Please help code a cystoscopic placement of a guide wire through a urethral stricture, urethral dilation and placement of a fully catheter both sequentially over the guide wire.
Answer (MF): When the patient is unable to pass a catheter and you do a cystoscopic examination, and find a urethral stricture with a small opening. You pass a very small guide wire through the opening and coil it into the bladder. Over this guide wire, you're going to place dilating instruments. And you'll dilate that stricture using the guide wire as a guidance getting by the stricture and into the bladder. Now, if you dilate the stricture, then you pass a special catheter that has an opening at its tip. You pass the catheter over the guide wire. And the catheter follows the guide wire into the bladder.
Once you get flow of fluid out of the catheter as the fluid passes around the guide wire, you blow up the balloon, pull it snug against the bladder neck and take out the guide wire. Now, when you do anything like that where you pass a wire, you do a cystoscopy and a urethral dilation, that billing and you can do the urethral dilation by any manner that you want whether it's Van Buren Sounds, whether it's through a guide wire or whether it's with fill up forms and follow it's the cystoscopy and dilation in any sequence.
The code that you should use is the 52281. That's cysto and urethral dilation. Now, that code also includes the placement of catheter. So you can bill another catheterization code. It's included in that code. That code happens to be a rather well paying code because you do extra work. Now the diagnosis for using that code 52281 should be urethral stricture or could it be false passage. However, if you have a patient that has a congenital or he's a small person and has a small lumen or his urethra but he doesn’t have a stricture, that's the way he is, he just has a small lumen and you dilate that lumen to facilitate the cystoscopic examination, then you should not use the code 52281. But in this particular problem, you do have a urethral stricture. Your ICD diagnosis which gives you the medical necessity or the reason for this procedure and for doing the 52281 would be urethral stricture.