• Medical Necessity

  Clearly define why the procedure was required (e.g., obstruction, recurrent stones, infection).

• Stone Size

  Important for supporting the procedural approach and sometimes device used.

• Stone Location

  • Kidney (renal pelvis/calyces)
  • Ureter (proximal, mid, distal)

• Surgical/Procedural Approach

  Specify the technique used:

  • ESWL (Extracorporeal Shock Wave Lithotripsy)
  • PCNL (Percutaneous Nephrolithotomy)
  • Endoscopy (e.g., ureteroscopy with/without lithotripsy)
  • Pyeloscopy

• Stents (If Used)

  Include if a stent was placed, exchanged, or removed, as this impacts coding and reimbursement.

• Shockwave Lithotripsy (ESWL)

  Code	Description
  50590	Extracorporeal Shock Wave Lithotripsy (ESWL)

• Percutaneous Nephrolithotomy (PCNL)

  Code	Description
  50080	PCNL for kidney stones up to 2 cm
  50081	PCNL for kidney stones larger than 2 cm

• Ureteroscopy with Laser Lithotripsy (Only one lithotripsy per side may be billed)

  Code	Description
  52356	Ureteroscopy with lithotripsy and stent placement
  52353	Ureteroscopy with lithotripsy (without stent)

• Manipulation, Basket Removal, or Vacuum

  Code	Description
  52320	Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus
  52330	Cystourethroscopy with manipulation without removal of ureteral calculus
  52352	Cystourethroscopy, with ureteroscopy and/or pyeloscopy with removal or manipulation of calculus

• Insertion of an Indwelling Stent

  Code	Description
  52332	Cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type)

• Modifier Use

  • Modifier -59 (-XS) may be required when performing multiple stone procedures.
    Note: You may not report codes 52356 and 52353 on the same side with a -59 (-XS) modifier.
  • Modifier -22 is used when a procedure requires significantly more effort than usual.

    Example of Modifier 22 in Practice

    Scenario: Steerable Ureteroscopy with Suction Technology

    Standard procedure: Breaking stones with laser, relying on natural clearance.

    Enhanced procedure: Using suction to actively remove stone fragments, requiring additional laser work and extended scope manipulation.

    Documentation: “The procedure required 2 times the amount of operative time than the normal time to ensure a completely clear the kidney due to the number of stones, the structure of the stones resulting in irregular fracture and the anatomy of the kidney. Additional operative time was required to fully explore and evacuate stone burden, reducing post-op complications and risk of repeat stone formation.”

    Justification: This extra effort places the procedure in the statistical ‘tail’ of the standard bell curve, warranting higher reimbursement.

  • Modifiers -LT and -RT
    • Are required when a bilateral organ, such as the kidneys or ureters, is involved and a procedure is performed on only one side.
    • Are applied to unilateral procedures to differentiate between treatment on the left and right kidney or ureter.

• Global Period Awareness

  • Most kidney stone procedures have a 0-day global period. (Exceptions are the ESWL and PCNL procedures which have 90-day global periods.)

On a 70-year-old Medicare patient, a ureteral lithotripsy of a .4cm stone in the upper calyx of the right kidney was performed followed by ureteroscopy with basketing and removal of a fragment of the same stone. Ureteral stent was also inserted. What is the correct billing of this encounter?



Answer: 52356

Procedures performed on 66-year-old male with two separate calculi:

• Cystoscopy, right retrograde to confirm location of stones. (52005)
• Ureteroscopy with Basket removal.3 stone – Lower 1/3 Right ureter. (52352)
• lithotripsy .7 stone - right renal pelvis. (52353)
• Insertion of a right renal indwelling stent. (52332)

Procedures performed on 66-year-old male with two separate calculi:

• Cystoscopy, right retrograde to confirm location of stones. (52005)
• Ureteroscopy with Basket removal.3 stone – Lower 1/3 Right ureter. (52352)
• lithotripsy .7 stone - right renal pelvis. (52353)
• Insertion of a right renal indwelling stent. (52332)