Urology Coding Alert

Question: A patient underwent a procedure to remove ureteral calculi. During the same encounter he also had a transurethral resection of a prostatic fossa mass that appeared to be papillary in nature. I plan to report the calculi removal with 52356. Should I code the prostatic fossa mass resection with 52601 or 52204?

South Dakota Subscriber

Answer: From your description this appears to be a papillary lesion suggestive of a transitional cell tumor of the prostatic urethra. Therefore, under the heading of “urethra and bladder “in the CPT® manual, code for a small transurethral resection of a tumor, code 52234 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)). Transurethral resection of a prostatic urethral fossa papillary mass with either code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)) or 52204 (Cystourethroscopy, with biopsy(s)) would be incorrect coding for the above clinical scenario.

Code 52356 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)) is correct for the ureteral calculi removal, as you suggest.