Urology Coding Alert

Question: My doctor documented the following procedure "cysto, bilateral ureteroscopy, bilateral stents, biopsy and laser ablation of a left renal pelvic malignant lesion, and laser ablation of a right malignant ureteral lesion." How should I report this procedure?

Colorado Subscriber

Answer: First, report 52332-50 (Cystourethroscopy, with insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) forthe bilateral JJ stent placements.

Additionally: You should report 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion) for the biopsy and ablation of the lesions. Since the urologist performed the same procedure on both sides for lesions in different locations -- one in the renal pelvis and one in the opposite ureter -- you should append modifier 50 (Bilateral procedure) to 52354.

The diagnoses you should report for this case would be 189.1 (Malignant neoplasm of renal pelvis) and 189.2 (Malignant neoplasm of ureter).