Urology Coding Alert

Question: The urologist performed a looposcopy with resection of a malignant urothelial carcinoma. I considered coding CPT 44386 , but the procedure was not just a biopsy. Am I correct in coding 44799 for an unlisted intestinal procedure, or is there a more appropriate code in this case? Should I also use 198.1 for secondary malignant neoplasm of other urinary organs?


Connecticut Subscriber


Answer: If the tumor removal constituted only biopsies, report 44382 (Ileoscopy, through stoma; with biopsy, single or multiple) or 44386 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; with biopsy, single or multiple).

Your choice depends on what type of diversion the urologist was examining: an ileal loop (44382) or a Koch or Indiana pouch (44386).

But if the removal of the intra-luminal tumors constituted a more invasive procedure - a true resection of the tumors - report 44382-22 or 44386-22. Modifier -22 (Unusual procedural services) indicates the more extensive nature of the tumor removal.

For the diagnosis, report 197.4 (Secondary malignant neoplasm of respiratory and digestive systems; small intestine, including duodenum) or 197.5 (... large intestine and rectum) instead of the less-specific 198.1 (Secondary malignant neoplasm of other specified sites; other urinary organs).

Also assign a code for the primary site of the neoplasm, or the history of the primary site, if known. If the primary site is not known, report 199.1 (Malignant neoplasm without specification of site; other).

Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis.