Urology Coding Alert

Question: I need help coding an “excision of ureteral polyp.” I found one code for the excision of urethral polyp, but that’s not what I need. The physician made an incision abdominally, incised the ureter to remove the polyp, and then sutured in layers, leaving a drain. What code should I use?

Florida Subscriber

Answer: CPT^® does not include a specific procedure code for open excision of a ureteral polyp or tumor. Therefore, you should consider an unlisted procedure code, such as 53899 (Unlisted procedure, urinary system). In some circumstances, code 50600 (Ureterotomy with exploration or drainage (separate procedure)) may also be appropriate.

Check your physician’s documentation to see which code better explains the procedure.

Tip: If you report 50600, attach modifier 22 (Unusual procedural services) to indicate the extra work of removing the polyp and suturing the ureter. You’ll need to send documentation and the operative report, along with an explanatory cover letter to the carrier. This code would also include the placement of a ureteral JJ stent.

Diagnosis coding: You’ll report N28.89 (Other specified disorders of kidney and ureter) with either procedure code for the diagnosis of “ureteral polyp.”