Urology Coding Alert

Question: My urologist performed a right antegrade flexible ureteroscopy, cystoscopy with transurethral resection of right ureteral orifice, conversion to right ureteral stent, and a nephrostogram. He was able to find the intramural ureter using resection down onto the antegrade ureteroscope. No evidence of tumor in the ureter or renal collecting system. He performed a retrograde placement of 8-French by 24 cm double-J ureteral stent and a 16-French 2-way Foley. I’m absolutely stumped on what CPT^® code to report for procedure since my urologist performed a cystoscopy with transurethral resection of ureter orifice only, and not a transurethral resection of bladder tumor (TURBT). Can you help me?

AAPC Forum Member

Answer: This sounds like a severe ureteral meatal/orifice stenosis/ stricture that needs an incision to open it. You should report 52290 (Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral) for the resection of the ureteral orifice stricture opening. Your diagnosis code would be N13.1 (Hydronephrosis with ureteral stricture, not elsewhere classified).