Urology Coding Alert

In the November 2000 Urology Coding Alert, two reader questions recommended using 52338 (cystourethroscopy, with ureteroscopy and/or pyeloscopy [includes dilation of the ureter and/or pyeloureteral junction by any method]; with biopsy and/or fulguration of lesion) to bill for a combination of surgical procedures that included a bladder biopsy. Even though it doesnt say so explicitly in CPT, 52338 (replaced by 52354 in 2001) is for biopsies done above the bladder, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Health Science Center in Stony Brook, and a privately practicing urologist and consultant for PRS, a coding consulting company in Denver.

There is room for disagreement regarding this issue. To be paid for the work of doing the biopsy, urologists say they need to bill more than 52335 (cystourethroscopy, with ureteroscopy and/or pyeloscopy [includes dilation of the ureter and/or pyeloureteral junction by any method]). But Medicare bundles 52204 (cystourethroscopy, with biopsy) and 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) into 52335. Unless you use modifier -59 (distinct procedural service), you cannot be billed for the biopsy and the ureteroscopy. The location of the lesion, however, does not justify modifier -59 because the definition for 52204 already refers to a biopsy in the bladder.

Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., recommends billing the two scenarios as follows:

Scenario one: Patient with hematuria. The physician performs a ureteroscopy on the left side with a retrograde pyelogram. A retrograde pyelogram is also preformed on the right side. A bladder biopsy is performed on the left bladder wall.

Coding recommendation: There may be differences based on the payer. Medicare does not recognize modifiers -RT or -LT for 52005, 52335 or 52204. Therefore, the most comprehensive code for this scenario is 52335. Because 52005 is the base code for 52335 and not billable separately if performed at the same session (endoscopy rules), it is not appropriate to break out that code. Code 52204 is also bundled by Medicare into 52335 and is not billable separately. Medicare will not pay separately for the bladder biopsy in this case.

A private payer, however, will probably pay for the bladder biopsy. For private payers, the coding recommendation is 52335-LT, 52005-59-51-RT and 52204-59-51.

For both Medicare and private payers, the urologist should code 74420-26 (urography, retrograde, with or without KUB, -professional component) if the urologist initially read the films, wrote a separate radiology report and acted clinically on the reading.

Scenario two: The urologist performed cysto and bilateral retrograde pyelogram, multiple biopsies and fulguration of bladder for bladder tumors.

Coding recommendation: Code 52224 (cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesions[s] with or without biopsy), 52005 and 74420-26 (if the urologist initially read the films, wrote a separate radiology report and acted clinically on the reading). The bladder biopsy has a range of codes (52224-52240) depending on size. If you use 52234-52240, Medicare will bundle it with 52005.

Note that some of the codes referred to above have been changed for CPT 2001. Code 52338 has been replaced by 52354 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of lesion). Code 52335 has been replaced by 52351 (cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic).