Urology Coding Alert

Question: Can we bill 52005 bilaterally in the office setting? The physician does the same procedure for each ureter.

Connecticut Subscriber

Answer: Whether this is done in the office or the hospital doesnt matter. Some commercial payers may pay for 52005 (cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) when reported bilaterally with modifier -50 (bilateral procedure). However, Medicare will not. According to the Medicare Carriers Manual (MCM), the basic procedure is an examination of the bladder and urethra (cystourethroscopy), which are not paired organs.

The work value for the code already takes into account that one or both ureters may need to be catheterized and examined.

No additional payment is made when the procedure is billed with bilateral modifier -50, the MCM states. Neither is any payment made when both ureters are examined and 52005 is billed with multiple surgery modifier -51. It is inappropriate to bill code 52005 twice, once by itself and once with modifier -51, when both ureters are examined.

In fact, Medicare has priced 52005 on the basis that it may be performed bilaterally. Medicare and private payers will pay the same fee for either unilateral or bilateral 52005. A few payers, particularly unions, recognize bilateral catheters and will pay an extra charge. Check with the payer, asking how they want it coded: one line with modifier -50 (52005-50), or two lines (52005 on the first line, 52005-50 on the second).

Tip: Code 52005 is site-dependent priced. Performed in the office, payment will increase by 70 percent to 75 percent. Remember also to charge for the pyelogram (74420 in the office, or 74420-26 in the hospital).