Urology Coding Alert

Reader Questions:

Discover Correct Transurethral Resection of Bladder Neck Code

Published on Thu Dec 09, 2021

Question: My urologist diagnosed the patient with urinary retention. On local cystoscopy, my urologist found the patient to have an enlarged bladder neck. The urethra had a tight meatus. The patient’s bladder neck was elevated and obstructed. The bladder had 2+ trabeculations without any stones or tumors. For the procedure, my urologist brought the patient to the cystoscopy suite and after proper time-out, general anesthesia was administered. My urologist then placed the patient in the dorsal lithotomy position, prepped, and draped in usual sterile fashion. All attempts at passing a 26-French visual operator were unsuccessful. My urologist then dilated the urethral meatus with sequential dilators from 18-French to 30-French. Then, my urologist passed the 26-French visual operator via the urethra into the bladder neck. My urologist removed the operator and placed the plasma button electrode in the sheath. My urologist vaporized the tissue to open up the bladder neck and urethral channel. My urologist achieved hemostasis with the plasma button and removed the scope. They placed a 22-French 3-way Foley catheter in the bladder for continuous bladder irrigation. Efflux was clear. The patient went to recovery in stable condition. What code should I report for this procedure?

AAPC Forum Subscriber

Answer: You should report code 52500 (Transurethral resection of bladder neck (separate procedure)) with the plasma button electrical vaporization.

Don’t miss: Since 52500 is a separate procedure, you should not report this code if your provider performs any other major procedure in the same anatomical location and during the same session.