Urology Coding Alert

Question: The patient had a bladder neck obstruction. My urologist placed the scope in the bladder without difficulty and noted a large median lobe. He resected the median lobe but left the lateral lobes alone. Once he had removed the couple of pieces of tissue of the medium lobe and had that wide open, he proceeded with the UroLift^®. Using the UroLift^® instruments, he placed four implants — two at the bladder neck and then two at the verumontanum. My urologist noted the anterior aperture to be adequate. The patient was started to spontaneous void at this time. After all chips were removed, good hemostasis was obtained. My urologist gave 10 mg of Lasix IV. He placed a 22 3-way catheter and gave a suppository. Finally, my urologist sent the patient to the PAR in stable condition and will follow up in a week or two with his PVR. My urologist is considering this procedure a “modified UroLift^®” because he resected the patient’s median lobe prior to placing the implants. Should I bill 52601 (Transurethral electro­surgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included))-52 (Reduced services) along with the UroLift^® codes?

AAPC Forum Subscriber

Answer: This is a clinical scenario in which two procedures are performed to accomplish one end result — opening the prostatic urethra to help in voiding. In these situations, according to CPT^®’s rules, you should bill the one procedure that most accomplishes the end result and not the two procedures. So, you should report just the appropriate code for the UroLift^®. In this case, you should report 52441, using one implant for an initial implant; and 52442, using three implants for the complete UroLift^®.