Cystolitholapaxy is a minimally invasive urological procedure that uses endoscopic fragmentation and evacuation to remove bladder stones. For medical coders and urology practices, selecting the correct CPT code ensures proper reimbursement and compliance with payer requirements.
Quick Answer
CPT code selection for cystolitholapaxy depends on stone size:
- 52317: Cystoscopy with litholapaxy for stones less than 2.5 cm (simple/small)
- 52318: Cystoscopy with litholapaxy for stones 2.5 cm or larger, or multiple stones of any size (complicated/large)
Both codes include cystoscopic visualization, stone fragmentation, and evacuation of fragments.
When to Use 52317 vs 52318
Follow this step-by-step process to determine the correct code:
Step 1: Confirm Procedure Elements
- Verify bladder stone location (not ureteral or kidney)
- Confirm fragmentation (litholapaxy) was performed
- Ensure evacuation of stone fragments occurred
Step 2: Measure Stone Size
- Review operative notes for largest stone diameter
- If largest stone is less than 2.5 cm, consider 52317
- If largest stone is 2.5 cm or greater, use 52318
Step 3: Assess Multiple Stones
- Multiple stones of any size in one session typically require 52318
- Verify with your payer, as some may allow 52317 for multiple small stones
Step 4: Rule Out Simple Removal
- If stones were grasped and removed without fragmentation, use 52310 or 52315 instead
- Litholapaxy codes specifically require fragmentation and evacuation
Related Codes (Choose Carefully)
Understanding related procedures prevents coding errors:
52310 - Cystourethroscopy with removal of foreign body, calculus, or ureteral stent from urethra or bladder (simple)
- Use when stones are removed by grasping without fragmentation
- Typically for very small stones that can be extracted intact
52315 - Cystourethroscopy with removal of foreign body, calculus, or ureteral stent from urethra or bladder (complicated)
- Use for complicated removal without fragmentation
- May involve multiple stones or difficult extraction
Key Distinctions:
- Cystolitholapaxy (52317/52318) requires fragmentation
- Cystolithotomy refers to open surgical removal through suprapubic incision (use 51050)
- Ureteroscopic procedures use different code families (52320-52356)
ICD-10-CM Linking (Examples)
Proper diagnosis coding supports medical necessity:
Primary Diagnosis Codes:
- N21.0 - Calculus in bladder
- N21.1 - Calculus in urethra (when appropriate)
- N21.9 - Calculus of lower urinary tract, unspecified
Supporting Diagnoses (when documented):
- R31.9 - Hematuria, unspecified
- R33.9 - Retention of urine, unspecified
- R30.0 - Dysuria
Important Notes:
- Always match diagnosis codes to operative findings
- Use laterality modifiers when applicable
- Avoid ureteral stone codes (N20.1, N20.2) for bladder procedures
Modifiers, Bundling & NCCI Tips
Understanding modifier use prevents claim denials:
Common Modifiers:
- -51 - Multiple procedures (when applicable)
- -59/-XE/-XP/-XS/-XU - Distinct procedural service
- -22 - Increased procedural services (with documentation)
- -80/-81/-82 - Assistant surgeon (when appropriate)
Bundling Rules:
- Diagnostic cystoscopy is inherent in 52317/52318
- Do not separately report basic cystoscopy (52000)
- Check NCCI edits before billing additional procedures
Payer Considerations:
- Global periods vary by payer (typically 0-10 days)
- Some payers require prior authorization for 52318
- Verify site-of-service requirements and RVU tables
Documentation Checklist
Ensure your operative notes include:
Essential Elements:
✓ Stone size (largest diameter in centimeters)
✓ Number of stones
✓ Exact anatomical location
✓ Fragmentation method (laser, pneumatic, ultrasonic)
✓ Confirmation of fragment evacuation
✓ Equipment used (lithotrite type)
Additional Documentation:
✓ Stone composition (if analyzed)
✓ Complications or unusual circumstances
✓ Images or photographs (when available)
✓ Reason for complexity (if using 52318)
✓ Any concurrent procedures performed
Common Denials (and How to Prevent)
Denial Reason: Missing Stone Size
- Prevention: Always document largest stone diameter
- Appeal Strategy: Submit imaging reports or operative photos
Denial Reason: Incorrect Code Selection
- Prevention: Use decision tree for 52317 vs 52318
- Appeal Strategy: Provide clear size documentation
Denial Reason: Unbundled Services
- Prevention: Review NCCI edits before billing
- Appeal Strategy: Use appropriate modifiers with documentation
Denial Reason: Diagnosis Mismatch
- Prevention: Align ICD-10 codes with operative findings
- Appeal Strategy: Submit complete operative report
Denial Reason: Missing Prior Authorization
- Prevention: Check payer requirements for 52318
- Appeal Strategy: Submit clinical notes supporting medical necessity
Quick Reference Table
| Scenario | Correct Approach |
|---|---|
| Fragmentation + evacuation; largest stone <2.5 cm | 52317 |
| Fragmentation + evacuation; largest stone ≥2.5 cm | 52318 |
| Fragmentation + evacuation; multiple stones (any size) | 52318 (verify with payer) |
| Removal without fragmentation (simple) | 52310 |
| Removal without fragmentation (complicated) | 52315 |
| Open bladder incision for stone removal | 51050 (cystolithotomy) |
FAQs
What is the difference between cystolitholapaxy and cystolithotomy?
Cystolitholapaxy uses endoscopic fragmentation through the urethra (52317/52318), while cystolithotomy involves open surgical incision into the bladder (51050).
Can multiple bladder stones be billed separately?
No. Multiple stones treated in one session typically use 52318. Each stone cannot be billed individually.
Is there a separate code for laser versus mechanical fragmentation?
No. Both laser and mechanical fragmentation methods are covered under the same litholapaxy codes (52317/52318).
When a stone is small enough to grasp without fragmentation, which code should I use?
Use 52310 for simple removal or 52315 for complicated removal. Do not use litholapaxy codes without fragmentation.
What diagnosis codes commonly pair with 52317 and 52318?
N21.0 (calculus in bladder) is the primary diagnosis. Supporting codes may include R31.9 (hematuria) or R33.9 (urinary retention) when documented.
Are global periods the same across all payers?
No. Global periods vary by payer and may range from 0-10 days. Always verify with specific payer policies.
What happens if stone size is not documented?
Claims may be denied or downcoded. Always document the largest stone diameter in centimeters for proper code selection.
Can I bill for cystoscopy separately with litholapaxy?
No. Diagnostic cystoscopy is bundled into litholapaxy codes and cannot be billed separately.
When should I use modifier -22 with litholapaxy codes?
Use modifier -22 for significantly increased complexity with supporting documentation, such as extremely large stones or unusual anatomical challenges.
How do I handle stones found in both bladder and urethra?
Code based on the primary procedure location and complexity. Document both locations clearly and consider appropriate modifiers for distinct sites.
