In February, our lunch and learn series titled “Coding and Documenting Genitourinary Procedures for Accurate CPT and ICD-10-PCS Code Assignment” had several questions regarding coding lithotripsy basket extraction of stones. Given the number of inquiries on this topic, the TrustHCS team wanted to dive a bit deeper in this area.

 

The Key Question

It seemed that many who attended the lunch and learn wanted to know, “When coding lithotripsy of renal calculi, do we code separately for the basket extraction of the stones?” The answer differs depending on whether you are coding CPT or PCS.

 

Coding CPT

If you are coding CPT, do not code separately for the basket extraction or removal of stones when performed after lithotripsy of renal calculi.  The stone removal would be part of the more definitive procedure – the fragmentation of the stones.

There may be times when the removal may be coded separately with modifier -59 appended. However, this is only when documentation supports one of the following, not ordinarily encountered or performed on the same day, by the same individual:

  • Different session
  • Different procedure or surgery
  • Different site or organ system
  • Separate incision/excision
  • Separate lesion
  • Separate injury (or area of injury in extensive injuries)

 

Coding ICD-10-PCS

When coding ICD-10-PCS, code for the removal of the solid matter and the fragmentation is inherent to the extirpation. Per “Urinary Calculi Fragmentation and Evacuation:  Coding Clinic, Second Quarter 2015:  Page 7 Summary”:

  • If a stone is fragmented and removed via basket extraction the fragmentation would not be coded. Only the removal which would be coded to the root operation extirpation.
  • If the patient has the stone fragmented one week ago and returns because the stone has not passed, the bladder stone is treated with ESWL and basket extraction.  Only the removal is assigned which would be the root extirpation.

For more answers to key coding related topics and complimentary CEUs, signup to join the TrustHCS monthly lunch and learn on-line session at www.trusthcs.com/lunch.