Post-ESWL obstruction: How to code for new stent

"First... you have to determine if you are in a global period," write Jonathan Rubenstein, MD, and Mark Painter.

Jonathan Rubenstein, MD

Mark Painter

My partner did an ESWL on a patient and included a note stating that the stent would be removed in 10 days at the office. On day 9, the patient came to the ER with an obstructed ureter on the same side and I removed the stent, pushed a stone into the kidney, lasered the stone, and inserted a new stent. What codes do I use for my services, and do I need a modifier?

First, as you suspect from the question, you have to determine if you are in a global period. Simply answered, you are in a global. As a partner of the same specialty, the payer will consider you as covering physicians and therefore subject to global billing rules as if your partner was treating the patient.

Also see: What are Category III codes, and how are they best used for billing?

Now that you know you are in global, you need to determine what modifier will be required to report the service. As the stone for the second procedure is on the same side, was not noted as pre-existing at the time of the first procedure, and your partner’s note does include a planned second procedure for removal of stone fragments or additional stone treatment based on size and procedure results (only a plan to remove the stent), the second stone treatment is considered a complication. Therefore, you will need to add a –78 modifier to the procedure for return to the OR during the global period for a related procedure.

Finally, you will need to select your code. Code 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) includes manipulation of the stone into the kidney, treatment with the laser, and insertion of the stent. Thus, you would report 52356-78. With the –78 modifier, you will be paid work value only.

Send coding questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times, at

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.


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