Simplifying stent removal coding: Understanding 52310 vs 52315

Can you help me clarify this billing controversy? I was told that we can bill the Current Procedural Terminology (CPT) code 52315 for bilateral stent removal, one from the left and one from the right ureter. Is that correct? Or is it not correct, unless the stents are encrusted?

Thank you for this question. Removal of stents using a cystoscope has been a common procedure in urology and is discussed frequently in our coding seminars and in this column. As we analyze your question, we need to look at the definitions of the 2 potential codes available for cystoscopy with removal of a foreign body:

• Code 52310: Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple

• Code 52315: Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated

For accurate reporting of codes, we need to focus on and understand the meaning of the last word included in the definition for each code: simple and complicated. What do these words mean in terms of this procedure? Simple and complicated in the context of these codes are defined by the effort and work involved, not by the number of foreign bodies, calculi, or stents removed. Even if it takes multiple passes to remove foreign bodies, calculi, and stents, if they are removed without any complexity, the simple code should be reported. Merely removing multiple stents or foreign bodies does not automatically make a procedure complicated. On the other hand, if it is complicated to remove a single foreign body or stent (if, for instance, the stent is significantly encrusted and considerable work and effort are required to break up the encrustations), then the complicated code should be reported. Ultimately, it is the work and effort needed, along with the appropriate documentation of that effort, that drive the appropriate code. The same would be true of a calculus in the bladder: If the effort to remove 2 or 3 calculi from the bladder were documented as simple, 52310 would be reported. If the effort to remove a single calculus were documented as requiring multiple attempts and significant manipulation, it would be reported with code 52315.

In short, based on the code description, we recommend basing the code selection on the documentation and the effort required to complete the service, and not the number of foreign bodies removed from the bladder.

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.