Urology Coding Alert

Question: I’m working on a surgical report that involves a right ureteroscopy, which I know to report as code 52351. The report also includes a right renal pelvic washing for cytology in addition to a basket extraction of clotted tissue from the right renal pelvis. How should I report these additional services?

Indiana Subscriber

Answer: While code 52351 (Cystourethroscopy, with ureteroscopy and/ or pyeloscopy; diagnostic) does encompass the underlying right ureteroscopy, you want to always be careful not to separately report any codes that better fit in a single, all-encompassing code. In this case, you have one code, 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion), that you can report that includes both the ureteroscopy and right renal pelvic washing.

However, to ensure 52351 meets all the right criteria for reporting, you must know how a renal washing for cytology purposes differs from a therapeutic renal washing. In this case, the renal pelvis washing is utilized as a method to perform a microscopic evaluation of cell morphology in preparations from urine. This is typically performed as a means of detecting renal pelvic cancer. From a coding perspective, this meets the criteria for a biopsy.