How do I code for percutaneous pouch lithotomy (stone in Indiana pouch) with lithotripter?

“If access to the Indiana pouch requires incision, code 51050 (cystolithotomy, cystotomy with removal of calculus, without vesical neck resection) or 51065 (cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus) would be more appropriate for removal of a stone from the Indiana pouch,” write Jonathan Rubenstein, MD, and Mark Painter.

The answer is determined by the surgical approach. Is the endoscope placed into the skin opening of the Indiana pouch using the current opening, or is a new percutaneous tract created directly into the pouch itself to perform the procedure?

If the “natural” new opening is used, the most accurate code to use is CPT code 52317 (litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small [less than 2.5 cm]) or CPT code 52318 (litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragmentscomplicated or large [over 2.5 cm]) based on the stone burden and based on whether this was felt to be a complicated procedure even if the stones were less than 2.5 cm. (Please describe in the operative note.) Current Procedural Terminology confirmed this in the 2016 editorial revision to guidelines under the endoscopy, cystoscopy, urethroscopy, cystourethroscopy subsection for these procedures. Because cutaneous urinary diversions utilizing ileum or colon serve as functional replacements of a native bladder, endoscopy of such bowel segments, as well as performance of secondary procedures, can be captured by using the cystourethroscopy codes. For example, endoscopy of an ileal loop with removal of ureteral calculus would be coded as cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus (52320).

The options for coding if a new percutaneous tract was created directly into the Indiana pouch should not include: CPT codes 50080 (percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm), CPT code 50081 (percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm), or CPT code 50561 (renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus). The important part of the descriptions of these 3 procedures is not the word “percutaneous” but rather the words “nephrostolithotomy or pyelostolithotomy” and “renal endoscopy,” meaning these codes describe percutaneous procedures specifically into the kidney itself, not a bladder or conduit.

If access to the Indiana pouch requires incision, code 51050 (cystolithotomy, cystotomy with removal of calculus, without vesical neck resection) or 51065 (cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus)would be more appropriate for removal of a stone from the Indiana pouch.

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

Questions of general interest will be chosen for publication. 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.