Urology Coding Alert

Question: I’m currently processing a surgical report that includes a right ureteroscopy, which I understand should be coded as 52351. The report also details a right renal pelvic brushing/washing for cytology and a basket extraction of clotted tissue from the right renal pelvis. How should I code these supplementary procedures?

Virginia Subscriber

Answer: While code 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic) does cover the basic right ureteroscopy, it’s always crucial to avoid reporting separate procedures that are more accurately represented by a single, comprehensive code. In this scenario, you have one code, 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion), which you can use to report both the ureteroscopy and right renal pelvic washing/ brush biopsy for cytology.

However, to confirm that 52351 is appropriately reported, it’s essential to understand the difference between a renal washing/brush biopsy for cytology purposes and a therapeutic renal washing. In this instance, the renal pelvis washing/brush biopsy is used to conduct a microscopic examination of cell morphology in urine samples, usually as a way to identify renal pelvic cancer. From a coding standpoint, this fulfills the requirements for a biopsy.