tci Outpatient Facility Coding Alert - 2019 Issue Q3

You Be the Coder: Append Appropriate Modifier for OR Complication Treatments

Question: Our physician performed a cystoscopy, a right retrograde pyelogram, and a right ureteroscopy with stent placement. In postoperative imaging, the stent was found to be incorrectly positioned. The patient returned to the operating room (OR) the next day for a stent removal. Should I report the stent removal? If so, do I report it with modifier 58 or 78? Mississippi Subscriber Answer: First, you’ll want to break the surgeries apart and report the respective CPT® codes. For the cystoscopy with right retrograde pyelogram, you’ll report code 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic) with modifier RT...

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