Urology Coding Alert

Visualize the codes to these bladder visualization procedures.

Because urologists frequently need to perform testing to more accurately diagnose patients, cystourethroscopies are extremely valuable during the diagnostic process. How? Because these procedures allow providers to visualize the bladder, urethra, urethral sphincter, prostate, and surrounding tissues, thereby helping urologists diagnose everything from lesions and foreign bodies to tumors and abscesses.

Coding these services, however, can create challenges. Not only does the cystourethroscopy code range (52000-52010) include confusing language, but many of these codes require documentation that urologists may not provide in great detail.

Check out a few tips (and one case study) and you’ll be on your way to cystourethroscopy coding bliss.

Consider Codes From 52000 Through 52010

The first step to understanding how to report cystourethroscopies is to pinpoint whether the operative note describes cystourethroscopy services alone or cystourethroscopies that include other services at the same time. The primary code for cystoscopy is 52000 (Cystourethroscopy (separate procedure)). Other codes for cystourethroscopy that also include additional services are:

• 52001 (… with irrigation and evacuation of multiple obstructing clots)
• 52005 (… with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service)
• 52007 (… with brush biopsy of ureter and/or renal pelvis)
• 52010 (… with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service)

Warning: If your urologist is in the habit of documenting just the word “cystourethroscopy” in their medical records, that could be an expensive mistake. The base code 52000 reimburses about $244 in the outpatient setting, while the other codes in the range pay significantly more, up to $459 for 52007, based on the 2023 Medicare Physician Fee Schedule.

Showing your urologists these value discrepancies could be a good way to inspire them to provide more thorough documentation if needed, since they surely want to collect more for their services when justified. That’s in addition to the importance of reporting correct codes, justified by the medical record, to stay compliant.

Fortunately, most urologists do tend to use the terms directly from the descriptors in their medical records. For instance, with 52001, you might see documentation of “irrigation” or “clots,” while notes for 52007 might use the term “brush biopsy.” However, if you don’t see terms that lead you to the right code, your best bet is to always query the urologist rather than just guessing or trying to “code close” to the procedure described by a particular code.

Challenge: Code This Cystourethroscopy Note

To better understand how to identify the right code from the operative note, check out this sample documentation and take note of the bolded words to help guide your code choice:

The patient was prepped and a rigid cystoscope was placed into the urethra to perform cystourethroscopy. Upon inspection of the bladder, both ureteral orifices have clear efflux. No evidence of bladder pathology. Bladder capacity was adequate. A #5-French cone tipped catheter was inserted into both ureteral orifices, followed by irrigation. Both ureters were normal. The upper collecting system was normal and the calices were sharp. Adequate drainage was noted bilaterally. The bladder was drained and inspected again.

As demonstrated by the bolded terms, this operative note describes a cystourethroscopy with ureteral catheterization and irrigation. Therefore, code 52005 is the most appropriate code for this service.

Bilateral question: Medicare does not allow you to report 52005 or the other cystourethroscopy codes bilaterally, so even though the urologist inspected both the left and right ureteral orifices in this procedure note, the single code covers the entire procedure, and you should not add bilateral modifiers.

If your urologist performs cystourethroscopy on a patient with private insurance, check whether the payer allows you to report bilateral modifiers (or multiple units) of the code. If so, identify whether you should use the LT (Left side) and RT (Right side) modifiers, modifier 50 (Bilateral procedure), or separate line items to reflect the bilateral nature of the procedure.

Torrey Kim, Contributing Writer, Raleigh, N.C.