Why 1 unit should be billed for cystoscopy with bilateral ureteral stent removal

“When taking into account the various rules surrounding both codes, 52310 or 52315 should be reported with 1 unit for the removal of bilateral stents,” write Jonathan Rubenstein, MD, and Mark Painter.

For cystoscopy with bilateral ureteral stent removal, how many unit(s) should 52310 be billed?

One unit should be billed. There are 2 codes available to report removal of a stent or foreign body: CPT codes 52310 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) and 52315 (cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; complicated).

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CPT code 52310 describes the work of removing an indwelling ureteral stent by cystoscopy, when the stent is visualized and then grasped using a grasping instrument to remove the stent. This procedure can be performed in the office, ambulatory surgical, or hospital setting. The code requires and includes performing a complete cystoscopy (CPT 52000), which cannot be billed separately, and therefore documentation should include the results of an examination of the urethra (such as for strictures), the prostate (in men), and the bladder (such as for mucosal lesions, neoplasms, or stones). CPT code 52310 is also the code used for simple removal of bladder stones or a bladder foreign body. Medicare has included in its rules a Medically Unlikely Edit (MUE) of 1 for this code with an indicator of 3, meaning that with medical necessity, more than 1 unit can be charged for the service but only under unique circumstances with appropriate documentation and payer review. Unfortunately, Medicare has also determined that code 52310 cannot be reported for bilateral services.

In addition to these payment rules, the clinical description for work involved includes the possible need for multiple passes into the bladder by stating, “Reintroduce the scope and remove the next, and all subsequent, stones in similar manner, until all stones have been removed. Reintroduce the cystoscope and inspect the bladder to assure no perforations or bleeding, then empty the bladder completely and slowly withdraw the cystoscope. If appropriate, insert a urinary catheter for postoperative drainage.” Because of this wording, CPT code 52310 would be billed once even for bilateral ureteral stent removal, and no modifier should be used in an attempt to bypass the edit.

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In contrast, CPT code 52315 specifically describes the complex removal of a stent. Medicare has assigned an MUE of 2 units to this code, meaning that Medicare will allow payment for this code with 2 units without record review. However, similar to code 52310, Medicare will not allow reporting of this code for bilateral services. The clinical description of this code would indicate that documentation should include the need to perform “twisting/torquing movement to try and dislodge some of the encrusted material from the stent.” Similarly, the provider may “regrasp the stent as often as necessary to try and remove the visible stone material, with the goal of atraumatically removing the stent intact from the ureter. Use fluoroscopy to monitor the progress of the stent as you slowly withdraw it from the kidney. Reintroduce the cystoscope, inspect the bladder, assure that there is efflux from that ureteral orifice, and irrigate the bladder using a Toomey syringe until all of the stone material has been removed.” This code should not be used for the removal of an encrusted stent that is easily removed, nor for the removal of bilateral stents.

When taking into account the various rules surrounding both codes, 52310 or 52315 should be reported with 1 unit for the removal of bilateral stents. However, if complex stent removal and complex stone removal are required for treatment of a patient, 52315 can be reported with 2 units.

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