Urology Coding Alert

Question: Our urologist performed a cystoscopic examination with incision of a left ureterocele, removal of distal ureteral calculus, and placement of left indwelling stent. How do I code these procedures?

Nevada Subscriber

Answer: You should report three codes for this procedure. First, report 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)) if the stone is removed ureteroscopically or 52320 (Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus) if your urologist removed the stone by grasping it with an instrument cystoscopically after the ureterocele had been opened exposing the stone.

Second, report 52300 (Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral) for the incision of the ureterocele.

Finally, report 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)) for the stent placement.

Include clear documentation of each procedure performed during the surgical encounter.