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

 

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

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


For the past 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.


 

Nephrostomy Nephroureteral Stent Nephrolothotomy CPT

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.

Leave a Comment

    Category

    Related blogs from Industry News , Medical Coding Tips

    ICD-10-CM Code Updates, April 2024

    As you know, CMS and the CDC release the majo...

    ICD-10-PCS Code Updates, April 2024

    In this Coding Tip, we present the new ICD-10...

    Excision vs. Resection ICD-10-PCS

    The focus of this coding tip is on the excisi...