Multiple stone removal coding: ‘X’ marks the spot

I have a question regarding coding for multiple stone removal. I have a physician who lasered five stones in five separate areas within the ureter and kidney. I am concerned as to how many times I can bill out 52353 on a single day. Have you heard of a limit?

There is no specific limit to the number of times you can charge a –59 modifier. However, what and how you charge for multiple stones on the same side of the urinary tract is confusing. We will discuss the Medicare rules first. Hopefully, you are well aware of the four new modifiers introduced by Medicare that were implemented Jan. 1, 2015:

  • XE–Separate encounter
  • XS–Separate structure/organ
  • XP–Separate practitioner
  • XU–Unusual non-overlapping services.

We strongly encourage you to use these modifiers instead of the –59 modifier for Medicare.

Therefore, the correct charges for multiple stones on one side, treated with the same procedure, would be 52353 or 52356 (if a stent is left indwelling) once for a stone(s) in the kidney, and 52353-XS once for a stone(s) in the ureter, since the ureter could be considered a different structure. You cannot charge separately for the other stones, nor should you charge twice for the insertion of a stent. The AUA is appealing that ruling. Fortunately, this year, the “X” modifiers alleviated part of the problem we dealt with last year.

For private payers, you should still use the –59 modifier, unless instructed otherwise under contract. The CPT Manual defines modifier –59 as follows:

“Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual” (2015 CPT Manual, Appendix A).

Certainly, it would appear that the –59 modifier should be added to any additional procedures requiring extra work that were not normally a part of the primary procedure. Although they do not mention stones specifically, the CPT Manual specifically states “different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury” (italics added for emphasis). Additional stones requiring additional work logically should qualify for the additional charge with the –59 modifier under either the different procedure definition or the different site inclusion.

Therefore, billing in the private sector should be:

  • 52353 or 52356 (if a stent is left indwelling) once for the first stone in the kidney
  • 52353-59 with 4 in the units box for the other four separately identified stones in the kidney and ureter or list 52353-59 on four separate lines.

Unfortunately, private payers do not always pay based on logic. And as we have all seen, private payers quite frequently adopt Medicare rules if Medicare rules allow them to pay a lower amount.

Can you explain how to bill multiple extracorporeal shock wave lithotripsy procedures (50590) on the same day? Example: positioned the patient, treated the one in the ureter, repositioned the patient, then treated the second stone located in the kidney, both on the same side. I can’t use the modifiers RT and LT. I’ve tried putting it on two lines using the –59 modifier and on a single line with two units.

This is a real problem with no good answer for private payers. For 50590 (Lithotripsy, extracorporeal shock wave), some payers—erroneously, we think—will only pay once because you performed a “lithotripsy.” It doesn’t matter how many stones or how many positions. Please see the previous answer for description of modifier –59, which should be attached to a second charge procedure and should be paid if all are playing by CPT rules. It is a different site and requires extra work.

The charges would be:

  • 50590
  • 50590–59

However, if your payer is not paying, don’t continue to bill it the same way. You might try adding a –22 modifier to receive some extra pay for the extra work. The charge would be: 50590-22.

For Medicare, you should charge:

  • 50590
  • 50590-XS

This is allowable since one stone is in the kidney and the second is in the ureter.