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| Section: |
Surgery |
| Number: |
S-23 |
| Topic: |
Urinary Stone Removal Procedures |
| Effective Date: |
August 1, 2005 |
| Issued Date: |
August 1, 2005 |
| Date Last Reviewed: |
06/2005 |
General Policy Guidelines
Indications and Limitations of Coverage
Several methods of urinary stone removal have been developed as alternatives to the conventional (incisional) approach. Among these are the following:
- Extracorporeal shock wave lithotripsy (ESWL)
This is a non-invasive technique which requires that the patient be immersed into a water bath in a device called a lithotripter. Underwater electrodes then transmit high energy shock waves that pulverize the stones. The particles are then passed through the urinary tract. ESWL is generally indicated for upper urinary tract stones. It is an eligible procedure when reported under codes 50590, S0400.
- Percutaneous lithotomy (lithotripsy)
This is a two-stage procedure first requiring a percutaneous nephrostomy with dilation of the nephrostomy tract. Subsequently, instruments e.g., nephroscope, basket, mechanical, electrohydraulic, lithotripter, etc., are inserted via the nephrostomy tube tract and the stones are removed. Percutaneous lithotomy is generally performed for kidney stones and should be reported under procedure code 50561.
A radiologist may perform the nephrostomy (e.g., 50040, 50392). This procedure is eligible for payment in addition to the stone removal, whether reported by the radiologist or the operating physician.
- Transurethral ureteroscopic lithotripsy
Transurethral ureteroscopic lithotripsy involves a cystoscopy with the passage of a ureteroscope. The stones can be fragmented using either ultrasonic or electrohydraulic techniques, and subsequently removed. Transurethral methods of ureteral stone removal should be reported using codes 52320, 52325, 52352, 52353.
- NOTE:
- Transurethral removal of bladder stones is a long-established procedure and should be reported using codes 52310, 52315, 52317 and 52318.
- Endoscopic laser treatment of ureteral calculi
Laser lithotripsy is another modality available for stone fragmentation. It is primarily utilized for the management of ureteral calculi. Endoscopic laser treatment is an eligible procedure and should be processed using code S2070.
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Procedure Codes
| 50040 | 50392 | 50561 | 50590 | 52310 | 52315 |
| 52317 | 52318 | 52320 | 52325 | 52352 | 52353 |
| S0400 | S2070 | | | | |
Traditional Guidelines
FEP Guidelines
PPO Guidelines
Managed Care POS Guidelines
Publications
References
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Glossary
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
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Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
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