Clarifying CPT 52353 billing for same-side stone cases

I am having a discussion with one of our urologists on coding for 2 stones on the same laterality. We read your publication “Update—Billing for Multiple Stones; August 20, 2018.” CPT 52353 has a Medically Unlikely Edit (MUE) of 1 with an MUE Adjudication Indicator of 2. Can you please help us understand the rationale for Scenario #7 from your publication:

Scenario #7: A 3-mm stone in the upper pole of the left kidney and a 4-mm stone in the left ureter; both stones were treated with ureteroscopy and lithotripsy.

Answer #7: Two separate stones in “separate organs” of the urinary tract.

Correct coding: 52353 and 52353-XS (-59 for private payers)

Jonathan Rubenstein, MD

First, we want to acknowledge that the MUE changed to include adjudication indicators in 2015.The implementation of the Adjudication indicators and our clear understanding of the indicators did take some time.It was our experience back in 2018 that many payers were allowing 2 units of code 52353 at the time we wrote the article.In retrospect we should have answer the question differently based on the adjudication indicator, which indicated was a 2-date of service.This type of Adjudication indicator is typically not one that can be appealed based on medical necessity.This reenforces our old adage that just because you get paid does not mean it was correct.Thank you for bringing this to our attention.

Additionally, we must remind you that the interpretation of CPT codes and the accompanying rules change occasionally. Given the same question today we would have answered that would report the treatment of 2 stones on the same side both treated with a laser differently based on the Adjudication Indicator and the following changes relative to laser treatment of stones.

In 2018, we provided an answer based on the position of the American Urological Association (AUA) that the kidney and ureter are 2 separate structures. The AUA’s position on this has not changed. What has changed is the payer interpretation of the parenthetical note included for codes 52332, 52353, and 52356. The parenthetical states: “Do not report 52356 in conjunction with 52332, 52353 when performed together on the same side.”

Mark Painter

Although we still believe that the parenthetical note’s intention should only be applied to the treatment of stones within the same structure, payers have now interpreted this note as an absolute and rarely allow reporting of the services for stones on the same side regardless of the stone’s location.

Unfortunately, this hard interpretation, even when challenged on appeal, is a war of semantics, and those writing the rule book (the payers) have the final say. Intention of CPT guidance is more difficult to defend, and the written guidance had been taken as the rule.

Some practices have found payers that will allow for billing of these services based on the AUA interpretation of structure and the intent of the parenthetical guidance; however, most have now adopted the newer hard interpretation of the note and do not allow billing for multiple stones treated with laser lithotripsy on the same side. If documentation supports a modifier -22 may be added to the 52353 or 52356 if multiple stones are treated on the same side using a laser to treat both stones.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.