Urology Coding Alert

Question: I’m attempting to code based on the following documen­tation: “Dome of the bladder. We used sterile water and a biopsy forceps. These two areas were biopsied and I cauterized the biopsy sites for hemostasis. I next performed flexible ureteroscopy of the reimplanted ureter. This showed no abnormalities … no tumors seen. A left retrograde pyelogram was performed. No filling devices were seen. We switched over to the rigid cystoscope. A right retrograde pyelogram was performed.” How do I report all of this?

Delaware Subscriber

Answer: You should submit 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic) and 52204 (Cystourethroscopy, with biopsy(s)); append either modifier 59 (Distinct procedural services) or XS (Separate structure/organ) to code 52204.

Explanation: Code 52351 suggests that the provider performs a diagnostic cystourethroscopy, with inspection of the interior of the bladder, the urethra, prostatic urethra, and ureteric openings using a cystoscope passed through the urethra and into the bladder, and also performs a ureteroscopy (inspection of the ureters) and/or a pyeloscopy (inspection of the renal pelvis). This code description does not describe the biopsy being performed. In this scenario, the provider performed a biopsy. Code 52204 includes biopsy, so there’s no need to report the biopsy separately.