Urology Coding Alert

Question: A patient had a pre-existing pathological urethral stricture. The physician dilated the urethral stricture then inserted the cystoscope to examine the urethra and the bladder. Because he performed the dilation before inserting the cystoscope, is the correct CPT^® code 52281? Or should we bill only 52000 because 53600 for the dilation is bundled with 52000?

North Carolina Subscriber

Answer: Based on the documentation provided, the most appropriate code is 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) because it includes both the dilation of the pre-existing stricture and cystoscopic examination. There’s no need to report separately 52000 (Cystourethroscopy [separate procedure]) or 53600 (Dilation of urethral stricture by passage of sound or urethral dilator, male; initial).