Urology Coding Alert

Question: My urologist saw a Medicare patient and documented the following operative procedures: "cysto, bilateral ureteroscopy, bilateral stents, biopsy, and laser ablation of left renal pelvic lesion and laser ablation of right ureteral lesion." How do I report these procedures?

Alabama Subscriber

Answer: Report 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion) for the biopsy and laser ablation of the lesions. Append modifier 50 (Bilateral procedure) since your urologist performed the same procedure on both sides for lesions in different locations -- one in the renal pelvis and one in the opposite ureter.

The diagnoses would be 189.1 (Malignant neoplasm of renal pelvis) and 189.2 (Malignant neoplasm of ureter). Then, report 52332-50 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type]) for the bilateral JJ stents.

Alternative: For many private and commercial payers that require two separate lines for the same bilateral procedures and do not recognize modifier 50, you should code for these bilateral procedures in the following manner:

• 52354-LT (Left side) for the biopsy and laser ablation of the left renal pelvic lesion with 189.1 as the diagnosis code
• 52354-RT (Right side) for the laser ablation of right ureteral lesion with 189.2 as the diagnosis code.