Urology Coding Alert

Question: According to the documentation, my urologist performed a cystoscopy. They drained a large amount of intestinal material from the bladder, along with food particles. Eventually, my urologist found the fistulous tract, and it was documented as “about 2 cm.” They performed a cystogram, which showed extravasation into the small bowel. How should I report the draining of intestinal particles from the bladder? Code 52001 doesn’t seem right because there’s no mention of blood or clots. Code 52000 doesn’t seem like enough. Code 51700 is out because it wasn’t therapeutic lavage. I’m almost leaning toward 52315 because intestinal contents and food particles are certainly a foreign body. Can you help me?

AAPC Forum Subscriber

Answer: Draining the intestinal particles from the bladder is not a separately billable service. You should consider it part of the cystoscopy to allow the urologist to view the bladder better. That means you’ll report just the code for the cystoscopy your urologist performed, which, without seeing the documentation, would likely be 52000 (Cystourethroscopy (separate procedure)). If there is additional documentation, be sure to check other code options.

You should not report 52001 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots), 51700 (Bladder irrigation, simple, lavage and/or instillation), or 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated) to cover the intestinal content removal, however.