CCSD code M2310 – Open surgical removal of a ureter stone

Key takeaways

CCSD code M2310 is open ureterolithotomy (including cystoscopy), a Chapter 12 urinary procedure in the Ureter section of the schedule.

The descriptor says open, so ureteroscopic, laser and nephroscopic stone operations take their own ureter codes.

Cystoscopy is part of the M2310 descriptor, so it doesn’t go on the claim as a separate line.

Major insurers usually require pre-authorization, so confirm it with the insurer for each patient before the surgery date.

Check the current status of M2310 in the CCSD schedule or with the insurer before you book, because codes are inactivated over time.

What CCSD code M2310 covers

CCSD code M2310 is open ureterolithotomy (including cystoscopy). It’s the code for removing a stone from the ureter through an open surgical incision. The ureter is the tube that carries urine from the kidney to the bladder.

M2310 sits in Chapter 12 of the CCSD schedule, Urinary system and male reproductive, in the Ureter section. Its M prefix is the letter shared by its kidney and ureter neighbors in the schedule.

CCSD (Clinical Coding and Schedule Development) sets the codes and their descriptors. Each insurer then prices them on its own fee schedule. Our CCSD guides for coders cover the rest of the schedule, code by code.

The full schedule sits behind a login, and codes are amended and inactivated through the CCSD publication cycle. Confirm that M2310 is still active in the current schedule, or with the patient’s insurer, before you book the case.

Inside the operation M2310 describes

The surgeon makes an incision over the stretch of ureter that holds the stone. The site depends on where the stone has lodged. The ureter is opened, the stone is removed and the ureter is closed.

The descriptor bundles in cystoscopy, the camera check of the bladder. So a cystoscopy done in the same session belongs to M2310 rather than to a second line on the claim. If the surgeon also places a ureteric stent, check the schedule before you add a separate stent code.

When open surgery is still the choice

Most ureteric stones are now treated through a ureteroscope or with shockwave lithotripsy. Open surgery is the exception, so an insurer reviewing an M2310 claim may ask why it was needed. The operative note usually answers with one of these:

• A large or impacted stone that endoscopic treatment couldn’t clear.
• A failed earlier attempt by ureteroscopy or shockwave lithotripsy.
• Anatomy that blocks safe endoscopic access to the stone.
• Another open procedure on the urinary tract in the same session.

Write the reason in plain terms. “Stone not accessible endoscopically after failed ureteroscopy” is stronger than a bare diagnosis.

M2310 or another ureter code? The approach decides

Ureter codes split mainly by route. An open incision points to M2310, while a scope through the urethra or the kidney points elsewhere. The table sets out the neighbors most often confused with it.

Descriptors are as listed on CCSD’s public code details and principles record for M3000. Check each one, and any unacceptable combinations, in the current schedule before you code. If the surgeon used a laparoscopic or robotic approach, search the schedule for the code that matches it. Don’t default to M2310, whose descriptor says open.

Shockwave lithotripsy of a ureteric stone has its own code too, M3110. The chart below adds it to the table’s codes and sorts them by route. Start from the approach in the operative note and read across to the code.

Pair M2310 with a ureteric stone diagnosis

Insurers look for the diagnosis, the approach in the notes and the CCSD code to agree. For M2310, the diagnosis is usually one of these ICD-10 codes:

• N20.1 Calculus of ureter.
• N20.2 Calculus of kidney with calculus of ureter.
• N13.2 Hydronephrosis with renal and ureteral calculous obstruction.

Code what the imaging and the operative findings show. A kidney-only stone diagnosis on an M2310 claim is a mismatch an insurer will query.

What the operative note has to show

The note is the evidence behind the code. A reviewer should be able to read it and arrive at M2310 without guessing.

• The approach. An open incision, named as such, with its site.
• The structure opened. The ureter, with the side and level of the stone.
• Why open surgery. The failed or unsuitable endoscopic route, in a sentence.
• The cystoscopy. Recorded as part of the procedure, not as a separate operation.
• Any stent or drain. What was placed, so the coder can check whether it bills separately.

Pre-authorization: Get it before the surgery date

Major insurers usually require pre-authorization for a planned operation like M2310. Confirm the requirement with the insurer for each patient, because it turns on the policy as well as the code. Request it once the decision to operate is made, and quote M2310 with the diagnosis code.

Store the authorization number on the case as soon as it’s issued. It has to appear on the claim, and a missing number is one of the easiest refusals to avoid.

How an M2310 claim moves from surgery to payment

Here’s the claim flow in order, from the booking to the remittance.

1. Check the code and the cover. Confirm M2310 is active in the current schedule and that the patient’s policy covers the operation.
2. Secure pre-authorization. Quote M2310 and the diagnosis, then record the number on the case.
3. Write the operative note. Capture the approach, the structure opened and the reason for open surgery.
4. Build the claim. Enter M2310, the diagnosis, the authorization number and the consultant’s insurer registration.
5. Apply modifiers only where specified. Use any modifier the CCSD Technical Guide specifies for the case, and none by habit.
6. Submit electronically. Healthcode is a main electronic route to UK insurers, but confirm each insurer’s accepted route.
7. Reconcile the payment. Match the remittance to the claim and follow up any shortfall or query promptly.

The anesthetist and any assistant usually invoice the insurer on their own claims. Check the insurer’s rules so their fees aren’t added to the surgeon’s M2310 line.

Fees vary by insurer and by the consultant’s agreement. Bupa’s code search tool shows its benefit for a CCSD code, and our Bupa CCSD codes guide explains how Bupa handles them.

A worked example: One stone, one clean claim

Take an illustrative patient with an impacted stone in the left ureter, confirmed on CT. Ureteroscopy fails to clear it, and the urologist plans an open operation.

The secretary requests pre-authorization with M2310 and N20.1, then records the number on the case. In the operating room, the surgeon performs cystoscopy, opens the left ureter and removes the stone. The note records the incision, the side and the failed ureteroscopy.

The coder enters M2310 alone for the procedure, with no separate cystoscopy line. The claim goes out with the diagnosis, the authorization number and the consultant’s registration. The anesthetist bills separately.

Before you submit: A six-point M2310 check

• M2310 is active in the current CCSD schedule, checked in the schedule or with the insurer.
• The operative note names an open approach to the ureter.
• The diagnosis is a ureteric stone code that matches the imaging and the findings.
• The pre-authorization number is on the claim and matches the code you quoted.
• No separate cystoscopy line sits beside M2310.
• Any modifier on the claim is one the CCSD Technical Guide specifies for this case.

Common M2310 mistakes, and the fix for each

• Adding a stent line by habit. The schedule decides whether a stent bills separately. Check it before the line goes on the claim.
• Coding a scope operation as M2310. Ureteroscopic and laser stone removal have their own codes. Match the code to the route in the note.
• Billing the cystoscopy twice. The descriptor includes it. Remove the extra line before you submit.
• Assuming the code is still live. Codes get inactivated. Check the current schedule before every booking, not once a year.
• Treating without authorization. Check the requirement with the insurer when the operation is planned, not after it.

How Pabau keeps M2310 claims moving

On many teams, the authorization number sits in an email, the note in one system and the claim in another. Pabau, the practice software we build for private practices, keeps all three on the patient’s case.

Prior authorization is tracked on the case, and Pabau warns your team when it’s missing. Through claims management, claims then go electronically to UK insurers via Healthcode and Bupa. Coding decisions stay with your surgeon and coder.

Send M2310 claims with authorization in place

Pabau tracks prior authorization on the case and warns your team when it’s missing. Claims then go electronically to UK insurers through Healthcode and Bupa.

Book a demo

Conclusion

M2310 is one of the simpler urology codes to get right, once the route is clear. Show an open incision into the ureter and a ureteric stone diagnosis. Then explain in the note why open surgery was needed, and the claim is easy to defend.

The harder part is timing. Check the code’s status and the authorization before the surgery date, because both are hard to fix afterward. Book a demo to see how Pabau keeps authorizations and Healthcode claims on one case for UK urology practices.

Continue your research

Was the stone in the kidney instead? CCSD code M0610 covers open removal of calculi from the kidney.

Treating a kidney stone endoscopically? CCSD code M0910 explains endoscopic fragmentation of renal calculi.

Only examining the ureter? CCSD code M3000 covers endoscopic examination of the ureter.

Coding other open ureter surgery? CCSD code M2510 covers ureterocele excision.

Billing Bupa for urology work? Bupa CCSD codes explains how Bupa processes CCSD-coded claims.

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