Urology Coding Alert

Question: The urologist's surgical note describes laser enucleation with morcellation of the prostate for a patient with a history of having had a Green-Light Laser procedure performed in the past. He documented the residual tissue and assigned code 52630. The CPT^® descriptor,  however, does not state "any method" for 52630, but there is a descriptor under 52601 to use 52630 for a repeat transurethral resection of residual tissue. Does that mean 52630 is the default code in this situation?

Alabama Subscriber

Answer: Sometimes the urologist will use another procedure to treat residual growth after an initial TURP, such as laser prostatectomy (52648, Laser vaporization of the prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed or 52649, Laser enucleation of the prostate with morcellation ...). If so, you should report the appropriate code for one of the laser procedures above, not the "second repeat TURP" code 52630 (Transurethral resection; residual or regrowth ...).

CPT^® code 52630 is used for a repeat TURP after an initial TURP. This patient's initial procedure was a laser prostatectomy subsequently followed by a repeat laser prostatectomy.