Urology Coding Alert

Question: During a cystoscopy while our patient was in a post-operative global period to a laser enucleation of prostate (CPT^® 52649), our provider identified an adherent, stone-like structure that was affixed to the right lateral wall, measuring 1-2 mm. The structure was excised with cold cup forceps. Would code 52310-79 be appropriate? At first we looked at 52224, but no fulguration was performed and it wasn’t classified as a lesion. 

Oregon Subscriber

Answer: The absence of the term “lesion” has no real bearing on the coding. Report code 52224 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy) for treatment of the 1 to 2 mm area excised endoscopically instead of 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple). Append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) to 52224.