Urology Coding Alert

Question: What procedure code should I use for an open bladder exploration for a diagnosis C18.7?

Indiana Subscriber

Answer: According to CCI guidelines, exposure and exploration of the surgical field is integral to an operative procedure and not separately billable. If the urologist performed another procedure related to the exploration on the same date, report the other procedure. Still include diagnosis C18.7 (Malignant neoplasm of sigmoid colon).

In the above scenario, a urologist explores the urinary bladder for a possible secondary tumor invasion of the bladder from a malignant sigmoid tumor and finds no bladder involvement. Since there is no specific CPT^® code for just exploration of the bladder, when you’re reporting an exploration of the bladder without any other procedure performed as in this case, code the possible reason for the exploration and add modifier 52 (Reduced services). Therefore, in this situation submit 51530 (Cystostomy; for excision of bladder tumor) and append modifier 52 to indicate only the bladder exploration was performed. Include ICD-10-CM diagnoses C79.11 (Secondary malignant neoplasm of bladder) and Z71.1 (Person encountering health services with feared condition which was not demonstrated).