Urology Coding Alert

Hint: Learn the modifier 26 guidelinesIf you don't know the proper surgical and radiological codes to report for your urologist's balloon dilation procedures, you could be under-reporting your urologist's services and procedures.Test yourself by coding this scenario submitted by Claire Kenny, CPC, in the urology division of the professional coding department at Lahey Clinic in Burlington, Mass. Start by analyzing the following surgical report (condensed for space purposes) and then compare your coding solution to the expert answer.Diagnosis (pre- and post-op): Recurrent urethral strictureProcedure: Cystoscopy, retrograde urethrogram, and urethral balloon dilationIndications: The patient is a 59-year-old man with history of panurethral stricture of unknown source who is status post a three-stage skin graft urethroplasty in 1980 with graft taken from the right lateral flank. He has since had multiple recurrent strictures requiring 30+ dilations over the past several years.He also had an episode of retention as well as a recent UTI. The patient has noted a significant decrease in the force and size of his urinary stream and was seen in the office yesterday, at which time the urologist passed a guidewire down the urethra but could not place a dilating balloon over this wire. He now presents for evaluation and dilation under anesthesia.Procedure: The urologist performed a retrograde urethrogram that showed a stricture in the membranous urethra and a distal pendulous urethra stricture.Next, the urologist attempted to pass the 17-French cystoscope but was unable to pass the cystoscope beyond the distal pendulous urethra. Therefore, the physician inserted a 4-French open-ended ureteral catheter into the bladder and passed the cystoscope over the ureteral catheter. The patient had a very dense stricture in the distal pendulous urethra, which the urologist navigated with the scope with much difficulty.The remainder of his pendulous urethra appeared of normal caliber. His prostatic urethra was normal with a normal verumontanum, but a high bladder neck.Inspection of his bladder revealed multiple trabeculations and several diverticula with the two largest diverticula on the left posterior bladder wall. He also had some erythematous bullous edema at the bladder neck, which had some erythema. These lesions appeared consistent with inflammation. However, the urologist sent the urine for cytology to rule out a malignancy.The urologist then removed the cystoscope. Next, he inserted a 9-French urethral balloon dilation catheter, inflating it and leaving it in place.Coding question: For this procedure, would you report 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female), or would you report 52000 (Cystoscopy), 53600 (Dilation of urethral stricture by passage of sound or urethral dilator, male; initial), 51610 (Injection procedure for retrograde urethrocystography), 52510 (Transurethral balloon dilation of the prostatic urethra), [...]