Urology Coding Alert

Question: The operative report shows that the surgeon completed pouchoscopy with biopsy of the ureter. Notes state, “Pouchoscopy was performed. The ureteral pouch anastomotic site with the ureter demonstrated papillary inflammatory appearing tissue which was biopsied x 3.” Would this qualify for 44386? And what would be the appropriate diagnosis code?

Iowa Subscriber

Answer: As per the 2019 CPT^® manual, “because cutaneous urinary diversions utilizing ileum or colon serve as a functional replacements of a native bladder, endoscopy of such bowl segments, as well as performance of secondary procedures can be captured using the cystourethroscopy codes.” Based on the information you shared, it appears that your physician inserted a scope into the pouch and took a biopsy of the pouch at the anastomotic site where the ureter joins the pouch. That points to code 52204 (Cystourethroscopy, with biopsy(s)). Viewing the pouch as a “replacement bladder” would be similar to taking a biopsy of the bladder at the site where the ureter attaches to the bladder in a patient who had bladder removal and pouch creation

For the diagnosis, consider waiting for the final pathology report to see if you can get a more specific code for that “inflammatory appearing tissue.” If the pathology does not lead to a definitive diagnosis, you can assign a diagnosis related to the signs or symptoms that prompted the physician to examine the pouch in the first place. You may also append diagnosis for “path pending” D49.4 (Neoplasm of unspecified behavior of bladder).