Urology Coding Alert

Question: A physician did a consult in the hospital and attempted to insert 16 french coude, 5 french spiral filiform and also attempted flexible cystoscopy and was unsuccessful, "unable to see in bladder." How should I code this?

North Carolina Subscriber

Answer: You will need two modifiers, -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and -52 (Reduced services).

To code the hospital consultation, choose the most appropriate code from the facility consultation codes 99251-99255 depending on the levels of history, examination and medical decision-making documented by the physician and append modifier -25.

For the attempted but unsuccessful dilation, you should report 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female) and append modifier -52 as an indication to the payer that the full service was not rendered. Be sure the attempts are documented in the operative report.