Urology Coding Alert

Question: According to the medical documentation, my urologist placed a 22-French rigid cystoscope into the bladder. No obvious urethral or bladder lesions were noted. Some inflammation was noted around the right ureteral orifice. The left ureteral orifice was normal. My urologist placed a 5-French open-ended catheter into the right ureter. Retrograde pyelogram revealed a slight dilatation of the right ureter with some blunting of the right calices. A questionable filling defect was noted in the mid-ureter. At this point, my urologist placed a 0.038 hybrid guidewire in the right kidney. The right ureteral orifice and distal ureter were dilated to a size 12-French with the ureteral dilator, and then a 6-French self-dilating ureteroscope was advanced. Some inflam­mation again was noted in the distal ureter. However, there was no stone noted, and the ureter was clear up to the level of the ureteropelvic junction (UPJ). Adequate drainage was noted from the right kidney, so the stent was not placed. If a physician uses a self-dilating ureteroscope, what CPT^® code best describes that procedure? Do I use 52351? The only codes I see for dilating the ureter is done to treat a stricture, and there’s no mention of that in OP note. Also, he didn’t use balloon dilation, laser, electrocautery, or incision as stated in the OP note.

Answer: You should just report 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic). You should only report the other codes if your provider documents that there was a ureteral stricture.