What modifier is applied when reporting cystourethroscopic removal of a self-retaining indwelling ureteral stent using codes 52310 or 52315?

Modifier for Cystourethroscopic Removal of Self-Retaining Indwelling Ureteral Stent

No modifier is required when reporting cystourethroscopic removal of a self-retaining indwelling ureteral stent using CPT codes 52310 or 52315.

Understanding Ureteral Stent Removal Coding

Ureteral stents are commonly used in urologic procedures to ensure good urinary drainage and relieve obstruction, pain, and infection 1. When reporting the removal of these stents using cystourethroscopy, the appropriate codes are:

• 52310: Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple
• 52315: Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated

Why No Modifier Is Needed

When performing a cystourethroscopic removal of a ureteral stent as a standalone procedure, no modifier is required because:

1. The procedure is being performed as the primary intervention
2. It is not being performed on the same day as another related procedure
3. The codes 52310 and 52315 already specifically include stent removal in their descriptions

Clinical Context of Ureteral Stent Management

Ureteral stents should be removed as soon as clinically appropriate, typically within 2-3 weeks for uncomplicated cases and no longer than 3 months for most clinical scenarios 2. Prolonged indwelling time can lead to complications such as:

• Encrustation
• Infection
• Patient discomfort
• Hematuria

Timing of Stent Removal

The timing for stent removal varies based on the clinical indication:

• Partial ureteral lesions: 2-3 weeks
• Complete ureteral transection with repair: 4-6 weeks
• Ureteral reimplantation: 2-4 weeks
• Temporary obstructions: 2-4 weeks after resolution
• Malignant obstruction: Regular exchanges every 3 months

When Modifiers Would Be Appropriate

While no modifier is needed for standalone stent removal, there are scenarios where modifiers might be used:

1. If the stent removal is performed on the same day as another procedure that is separately billable
2. If the stent removal is performed during the global period of a previous urologic procedure
3. If multiple stents are removed from different ureters

Complications of Delayed Stent Removal

It's worth noting that delayed removal of ureteral stents can lead to significant complications. A case report described a patient with a stent left in place for 6 years who developed encrustation with calculi formation, requiring holmium laser lithotripsy for removal 3. This underscores the importance of timely stent removal and proper coding to ensure appropriate patient care.