Urology Coding Alert

Question: My physician carried out a flexible cystoscopy. The anterior and posterior urethra were unremarkable. The bladder was inspected. The floor or dependent portion of the bladder had a large amount of tiny stones or sediment. There were no obvious large stones and no obvious tumors. At this time, my physician irrigated the sediment from the bladder through the scope and the patient tolerated the procedure fairly well. What CPT^® and ICD-10-CM codes should I report for this procedure?

AAPC Forum Member

Answer: Since your physician irrigated multiple tiny stones from the bladder, you should bill 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated) with ICD-10-CM code N21.0 (Calculus in bladder).

Don’t miss: If you look in the ICD-10-CM manual, you will see that code N21.0 also includes the following diagnoses:

• Calculus in diverticulum of bladder, and
• Urinary bladder stone.