Urology Coding Alert

Question: I need help coding an "excision of ureteral polyp." I found one code for the excision of urethral polyp, but that's not what I need. The physician made an incision abdominally, incised the ureter to remove the polyp, and then sutured in layers, leaving a drainage. What code should I use?


Florida Subscriber

Answer: There is no CPT code for open excision of a ureteral polyp or tumor. Therefore, you should consider an unlisted-procedure code, such as 53899 (Unlisted procedure, urinary system). At the same time, 50600 (Ureterotomy with exploration or drainage [separate procedure]) may also be appropriate.

Check your physician's documentation to see which code is best to explain this procedure.

Key: If you report 50600, attach modifier 22 (Unusual procedural services) to indicate the extra work of removing the polyp and suturing the ureter. You'll need to send documentation and the operative report, along with an explanatory cover letter, to the carrier. If the urologist also places a ureteral stent via the ureterotomy for postoperative drainage, also report 50605 (Ureterotomy for insertion of indwelling stent, all types).

Diagnosis coding: You'll report 593.89 (Polyp of ureter) with either procedure code.