Urology Coding Alert

Question: How should I report a cystoscopy with bladder neck contracture (BNC) dilation in a male patient when performed in an office or in a hospital operating room?

Alabama Subscriber

Answer: Since your urologist also performed a cystoscopic examination as well as the dilation, you should report 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female) rather than 53605 (Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction [spinal] anesthesia), which does not include a cystoscopic examination.

You will report the procedure using this code regardless of the place of service. Use 52281 whether he did the dilation and cystoscopic examination in the office under local anesthesia or in the hospital operating room (OR) with spinal or general anesthesia.