Urology Coding Alert

Question: A patient had a cystoscopy during the post-operative global period of a laser enucleation of prostate (CPT^® 52649). During the procedure, our provider identified an adherent, stone like structure, calcification that was affixed to the right lateral wall, measuring 1-2mm. She excised the structure with cold cup forceps. Would reporting this as 52310-79 be appropriate? At first we looked at 52224, but the urologist did not perform fulguration and it wasn’t classified as a lesion.

Oregon Subscriber

Answer: Your initial thought is correct: submit 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) with modifier 79 (Unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period) appended instead of 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple).

Use diagnosis D49.4 (Neoplasm of unspecified behavior of bladder) to represent “path pending” for the bladder lesion until you receive the pathology report. The absence of the term “lesion” or “fulguration” has no real bearing on the coding.

CPT^® code 52224 is for the excision of a minor bladder wall abnormality which may represent a bladder tumor. Code 52310 represents the removal of a bladder stone, stent, or foreign body lying freely within the bladder cavity. Bladder wall calcification may often represent an underlying bladder wall malignancy.