Urology Coding Alert

Question: My urologist performed a cysto, bladder biopsy, fulguration, hydrodistention, and heparin instillation. My urologist placed the scope in the patient’s bladder without difficulty. The patient had an erythema noted from the right lateral wall to the midline. They performed hydrodistention just to see what the capacity was, and it was 1000 cc. There were some petechiae hemorrhages noted in this area where the erythema was located. My urologist took a biopsy from the posterior wall and right lateral wall and sent for analysis. They then fulgurated this area where the biopsy sites were. At this time, no other masses or lesions noted. Both ureteral orifices were effluxing clear urine. My urologist decided to give the patient heparin instillation with some Solu-Medrol and Marcaine. They placed a #16 French Foley. The medicine was left in place for an hour. Which codes should I report on my claim?

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Answer: You should report 52260 (Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia) for the bladder distention if the patient’s diagnosis is interstitial cystitis. On the other hand, if the patient’s diagnosis is not interstitial cystitis, then the dilation would be included in the cystoscopy associated with code 52204 (Cystourethroscopy, with biopsy(s)). So, in addition to 52260 you would also report 52204-XU (Unusual non-overlapping service…) for the biopsy.

Don’t miss: Code 51700 is included in 52204 and is not separately billable.