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Stents and Catheterization Procedures

Q. What is the difference between temporary and permanent stents?

A. According to CPT® definition in the guidelines of the Ureter and Pelvis section, temporary stents are those that are inserted at the beginning of a surgical procedure and then removed once the procedure has been completed. A permanent stent is a stent that is inserted during the surgery but will be removed at a later date.

However, this wording reflects the fact that in the early days of endo-urology, all catheters inserted into ureters were referred to as "stents" and the two terms were used interchangeably. Subsequently technology has evolved and virtually all stents are designed to remain indwelling in the patient. Ureteral catheters, on the other hand are typically inserted and removed in the same therapeutic intervention.

Temporary ureteral catheters are open-ended straight tubes which are placed within the ureter to perform retrograde pyelography or to collect selective ureteral urine for cytology. In contrast, insertion of an indwelling or non-temporary stent (CPT® code 52332) involves the placement of a specialized self-retaining stent (e.g. J stent) into the ureter to relieve obstruction or treat ureteral injury. This requires a guidewire to position the stent within the kidney. The ends of the stent are coiled so that one end is anchored in the renal pelvis while the other is in the bladder thereby preventing migration. These indwelling stents are not removed at the same patient encounter. It follows that when CPT® code 52332 is reported with any of the codes in this family (52320-52355) it is being used to report insertion of an indwelling stent, and not a temporary ureteral catheter (52005). It would be expected that the operative procedure note would reflect the appropriate procedures performed. (See questions below regarding removal).

Q. How do I bill for urinary bladder catheterizations?

A. There are several codes for this procedure. A brief description of each follows:

CPT® code 51701	Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine): This code is used when a non-indwelling bladder catheter is inserted and immediately removed after urine is obtained for diagnostic purposes, i.e., sterile urine specimen (commercial payers only) or a post-voiding residual urine (commercial or Medicare).
CPT® code 51702	Insertion of temporary indwelling bladder catheter; simple (e.g., Foley): Use this code for the routine insertion of an indwelling bladder catheter, such as a Foley. The patient will leave the office with the catheter in place using leg bag drainage.
CPT® code 51703	Insertion of temporary indwelling bladder catheter; complicated (e.g., altered anatomy, fractured catheter/balloon): Use this code when the insertion of an indwelling bladder catheter cannot be performed easily due to altered anatomy or if an already inserted catheter cannot be removed because of a defect in the catheter itself, i.e., fractured catheter/balloon. The determination of difficulty should be made by the physician who successfully passes the catheter. For example, this code is not appropriate if another health care professional cannot insert the catheter and the urologist then easily inserts it. This code should only be used for difficult insertions.
HCPCS code P9612	Catheterization for collection of specimen, single patient, all places of service: This is an existing HCPCS code used for Medicare claims only when the urine specimen is obtained from a patient using a straight catheter. The specimen is then used in a urinalysis, urine culture or sensitivity study. Do not use CPT® code 51701 for a specimen obtained by catheterization for Medicare claims. CPT code 51701 is straight catheter for residual urine. Private carrier may adopt Medicare policies; so please double check with your private carriers.

Q. A patient came to our office for a stent exchange. How do I bill for the removal and reinsertion of bilateral stents in the office?

A. CCI edits include the code for the removal of the stent, CPT® code 52310, Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple and its counterpart CPT® code 52315 complicated into the insertion CPT® code 52332 Cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type). Separate reimbursement is no longer allowed for a stent removal performed on the same day under any circumstance. No modifier may be used to unbundle these codes. For commercial payers, reimbursement will depend on any contractual agreements and internal bundling rules. It is appropriate to bill the CPT® code 52332 with modifier -50 Bilateral Procedure, to indicate the procedure was done bilaterally.

Q. How do you charge for stent removal when the urologist did not perform a cystoscopy and removed the stent just by pulling the string?

A. There is no CPT® code for stent removal by string. The urologist should not bill separately for this procedure. This type of removal would be included in an associated E&M service. If the removal was performed in the postoperative global period of a prior surgery, the removal is included in the postoperative care and is not reimbursed.

Q. How do you code for teaching patients to perform clean intermittent catheterization?

A. This teaching is included in the E&M service. Keep in mind that the face-to face time with the patient in a teaching situation may be the determining factor in selecting the E&M level.

Q. An office medical employee changed a Foley catheter while the doctor was in the office. Can we bill for this?

A. Yes, if a qualified provider is in the office, the changing of a urinary Foley catheter or suprapubic catheter may be charged under incident to requirements. For changing of a urinary catheter use CPT® code 51702 Insertion of temporary indwelling bladder catheter; simple (e.g., Foley) or CPT® code 51703 complicated (e.g., altered anatomy, fractured catheter/balloon). For changing of a suprapubic catheter, use CPT® code 51705 Change of cystotomy tube; simple or CPT® code 51710 complicated.

Q. How do I bill for a cystoscopy with retrograde pyelogram performed on both ureters?

A. Billing rules are different between Medicare and commercial insurers.

According to the Medicare Carriers Manual, Section 15200, there are specific instructions for billing a bilateral retrograde pyelogram: CMS Manual

CPT Code 52005 has a zero in the bilateral field (payment adjustment for bilateral procedure does not apply) because the basic procedure is an examination of the bladder and urethra (cystourethroscopy), which are not paired organs. The work RVUs assigned take into account that it may be necessary to examine and catheterize one or both ureters. No additional payment is made when the procedure is billed with bilateral modifier "-50." Neither is any additional payment made when both ureters are examined and code 52005 is billed with multiple surgery modifier "-51." It is inappropriate to bill code 52005 twice, once by itself and once with modifier "-51," when both ureters are examined.

Commercial carriers may have their own rules on coding bilateral retrogrades. Contact your carrier to determine their billing requirements.