Coding Tip: Reporting “Exchange” of ureteral stent in ICD-10-PCS

 

When a patient presents with hydronephrosis for exchange of ureteral stent via cystoscopy two PCS codes would be reported. This would be coded as “removal” of the stent and then “dilation” for the insertion of the new stent. The objective of the procedure is to dilate the ureter and not change the device. AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Second Quarter 2016, Pages 27 & 28 have a perfect example of this procedure with explanation.

 

Root Operation Definitions:

• Change—Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane.
• Removal—Taking out or off a device from a body part
• Dilation—Expanding an orifice or the lumen of a tubular body part

References
AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter, Page: 111
AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Second Quarter 2016, Pages 27 & 28

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.