Outpatient Facility Coding Alert

Question: The doctor injected Botox in the patient’s bladder wall and then injected two syringes of Durasphere at the 8 o’clock and 4 o’clock positions at the mid-urethra. Would 52287 be reported separate because there were two different locations at the bladder and the urethra or are they considered bundled?

Texas Subscriber

Answer: In this clinical scenario, first report 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck) for the injection within the mid-urethra. 

Then, report 52287 (Cystourethroscopy, with injection[s] for chemodenervation of the bladder) for the Botox injections into the bladder. Attach modifier XS (Separate structure) to 52287 since the bladder is a separate organ from the urethra.  Modifier 59 may also be utilized depending upon payer policy.

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