Below is an example of a common cystoscopy procedure as well as the ICD-10-CM codes that should be assigned for this outpatient encounter.

Outpatient Case Study
Postoperative Diagnosis: Left urolithiasis with obstruction

Procedure: Cystourethroscopy, left retrograde pyelogram, left ureteroscopy with stone extraction and stent placement

Anesthesia: General

Procedure Description: After informed consent was obtained, the patient was brought to the operating room, placed on the table in supine position. He was then given a general anesthetic and placed in dorsal lithotomy position. He was prepped and draped sterilely. 

Cystourethroscopy was performed using a 21-French rigid cystoscope with video assistance. This showed a normal anterior urethra. Prostatic urethra was also normal consistent with minimal, if any, BPH. Upon entering the bladder, there was some cloudy urine coming from the left ureteral orifice. A retrograde pyelogram was then performed using a 50:50 mix of Conray and sterile water, and an 8-French cone-tip catheter. This showed several small filling defects in the distal ureter, approximately a centimeter up from the ureteral orifice, which was consistent with the stone seen on the CT. The cystoscope and the cone-tip catheter were then removed. 

A 0.035 French Sensor Dual-Flex guidewire was then passed through the cystoscope and up into the renal pelvis and coiled under fluoroscopic guidance. The Olympus 9-French ureteroscope was then used to perform distal rigid ureteroscopy. The stone fragments were seen at the distal ureter. Initially, I was going to use a laser, but due to a laser malfunction, I decided to try to basket these stones since they were fairly small. I was able to successfully basket the three largest fragments, and these were then sent to pathology for evaluation. The remainder, if any, fragments were way too small to be retrieved successfully using the 1.5- French stone basket. At this point, the patient's ureter appeared to be stone-free. I decided to leave the stent there, given the appearance of the distal ureter due to stone fragments. A 4.6 x 30 cm double J ureteral stent was placed without difficulty. 

The patient tolerated the procedure well.  His bladder drained, and he was taken to recovery in stable condition.

ICD-9 and ICD-10 Code Assignments
Listed below in the first table is a comparison of the ICD-9 diagnosis codes and the ICD-10 diagnosis codes. As you can see, although the codes differ, the descriptors are identical.

As mentioned in previous columns, each digit of the ICD-10 diagnosis code is a specific identifier. Here's what the above code N20.1 indicates:

N = Chapter 14 - disease of genitourinary system;

20 = urolithiasis; and

1 = ureter.

Now review the second table below, which compares the ICD-9 procedure codes against the ICD-10 procedure codes, where you will see a wide variance in the descriptors. However, please note that we are showing these only to illustrate a point because, in the outpatient setting, these ICD-9-CM procedure codes would not be reported per HIPAA guidelines.

Like the ICD-10 diagnosis codes, each digit in the ICD-10-PCS column identifies a specific feature:

O as the first digit = Medical surgical, and B as the first digit = imaging;

T as the second digit = urinary system;

J as the third digit = inspection, B = excision, 7 = dilation, O = plain radiography;

7 as the fourth digit = left ureter;

8 as the fifth digit = endoscopy via natural opening;

Z as the sixth digit = no device, and D = intraluminal device; and

Z as the seventh digit = no qualifier.

CPT Procedure Codes
In addition, for the above outpatient case, you will need to assign the following CPT procedure codes.

52352        Cystourethroscopy with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)

52332        Cystourethroscopy with insertion of indwelling ureteral stent

52005        Cystourethroscopy with ureteral catheterization with or without irrigation, instillation or ureteropyelography, exclusive of radiological service (pyelogram) is bundled into code 52352 per NCCI edits and should not be assigned.

Information Source: The following are the links to access the latest version of ICD-10-CM and ICD-10-PCS.

http://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm and http://www.cms.hhs.gov/ICD10/01m_2009_ICD10PCS.asp#TopOfPage

Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.