Urology Coding Alert

Question: My urologist was called into surgery by an ob-gyn who thought she had injured the ureter during a procedure. He performed a cystoscopy with retrograde pyelogram and found no injury. I'm pretty sure of my CPT coding, but am stuck on the diagnosis code. How should I report this procedure?

Alabama Subscriber

Answer: Your urologist performed the examination and radiological study because of a ureteral injury. Therefore, you should first report 867.0 (Injury of ureter). Then use V65.5 (Suspected problem not present) as a secondary diagnosis. This is a good way to indicate to the payer that your urologist performed an examination but did not find any pathology.

Your CPT coding should be 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiological service) for the cystoscopy and 74420-26 (Urography, retrograde, with or without KUB; Professional component) for your urologist's interpretation of the retrograde pyelogram.