Urology Coding Alert

Question: How should I report a cystourethroscopy during which the urologist uses one scope and takes three tissue samples of the bladder?

New Hampshire Subscriber

Answer: You should report the cystourethroscopy just once even when a urologist performs multiple biopsies at separate sites. That doesn't mean you won't be able to seek additional reimbursement for the physician's additional work when he obtains more than one biopsy.
 
Append modifier 22 (Unusual procedural services) to show that the physician took more than one biopsy. Be sure you have documentation showing that the procedure involved extra time and effort by the urologist in case the carrier requests the medical records for review prior to payment.
 
Example: For the scenario in your question, you should report 52204 (Cystourethroscopy, with biopsy) with modifier 22 appended to the procedure code.
 
Caveat: Some Medicare carriers, such as in New York and Idaho, continue to reimburse at times for multiple bladder biopsies. Therefore, you should always ask your individual carriers how they want you to report multiple biopsies.