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February 10, 2015 - Updated: 11.09.16

NOTE: This article has been revised to remove the following documentation requirement:

4. Documentation of urinalysis (or urine culture or dipstick) results performed prior to the procedure, including treatments, if needed to treat identified infection

Cystourethroscopy with Insertion of Indwelling Ureteral Stent (CPT Code 52332): Documenting Urinalysis to Support Medical Necessity

Reducing Medicare payment errors is a major focus for CMS and its contractors, including CGS. This effort has prompted several auditing projects designed to identify and recover improper payments, many of which are due to documentation errors.

Crucial information about medical necessity is often missing from ureteral stent insertion documentation. The major area of concern in reviews of these services is that results from urinalysis or urine culture performed prior to the procedure are not provided in response to an Additional Documentation Request (ADR) from CGS. According to the American Urological Association, untreated bacteriuria can lead to infectious complications and possible urosepsis if combined with urinary tract obstruction, endourologic manipulation or shock wave lithotripsy. Infectious complications of endourologic manipulation, including urosepsis, increase the direct costs of hospitalization, the length of stay and the required level of care and result in increased morbidity and mortality. Urine analysis, urine culture or urine dipstick testing (in uncomplicated cases) is highly recommended prior to elective endourologic manipulation including the placement of urinary stents. In case of suspected or proven infection, appropriate antibiotic therapy should be administered before intervention.

The requirement for this documentation is supported by the American Urological Association's Best Practice guidelines. The pre-operative identification and treatment of a urinary tract infection decreases the patient's risk of developing bacteremia during and following the procedure and thereby improves patient outcomes. Documentation of these factors is required in order to show the procedure is medically reasonable and necessary at the time it is performed.

Documentation Requirements

Documentation submitted in response to an ADR letter for cystourethroscopy with insertion of indwelling ureteral stent (CPT code 52332) should include the following:

History & Physical, or part of operative/procedure report, of the indication for the procedure including but not limited to the following situations:
1. Ureteral obstruction secondary to nephrolithiasis, intrinsic/extrinsic tumor, retroperitoneal fibrosis, or ureteral stricture
2. Prophylactically prior to ESWL or following a complicated ureteroscopy
3. Following a ureteral anastomosis to ensure continued urine flow
Procedure/operative report clearly indicating the nature of the procedure performed
Fluoroscopic verification of adequate stent placement (ultrasound in the pregnant patient)