Urology Coding Alert

 Question: I am coding for a procedure based on this op note: “The cystoscope was inserted into the bladder, and a flexible ureteroscope was advanced into the ureter and then into the kidney. A 200 micron laser fiber was then inserted. I used this to ablate the tumor. About 10 to 15minutes of ablation was required. I was able to ablate what appeared to be the entire tumor as well as the base.”

Which CPT^® code applies to this approach with a laser ablation of a renal pelvic tumor? Would I use 52355 for an ablation using the laser or would I need to use an unlisted code?

New Mexico Subscriber

Answer: Based on the operative note, the surgeon performed a laser ablation rather than tumor resection. Therefore, code 52355 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor) seems inappropriate. A better option based on the information you share is 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion).