Urology Coding Alert

If 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 stricture

Procedure: Cystoscopy, retrograde urethrogram, and urethral balloon dilation

Indications: 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), and 74420-26 (Urography, retrograde, with or without KUB; professional component)?

"I have been billing 52281 and 74420-26 only and wonder if I'm too cautious," Kenny says.

CPT coding principles state that you should report only one code if that one code encompasses the multiple procedures or services your urologist performed. Therefore, the first code you should report in this scenario is indeed 52281. This code accurately represents the urologist's work of performing the cystourethroscopy, stricture dilation and the retrograde injection for the urethrocystography.

Next: You should report radiology code 74450 (Urethrocystography, retrograde, radiological supervision and interpretation) rather than 74420 for the retrograde urethrogram, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.

Modifiers: Be sure to append modifier 26 to 74450 to indicate that the urologist only performed the interpretation of the urethrogram. Generally, if a physician conducts diagnostic tests or other services using equipment she doesn't own (like at the hospital), you should append modifier 26 to indicate that she provided only the physician component (the interpretation) of the service, says Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board.

But if the physician does the procedure (in its entirety) in the office with equipment owned by the practice, you don't need a modifier, she adds.

"Code 74420-26 is for the interpretation of a retrograde pyelogram, a radiological study of the kidney pelvis and ureter, not of the urethra," Ferragamo says.

Tip: If the far-left column of the CMS Physician Fee Schedule database lists separate values for the code with modifiers 26 and TC, modifier 26 would be appropriate if your urologist provides only the service's professional component. You can download the fee schedule from the CMS Web site http://www.cms.hhs.gov/PhysicianFeeSched/.

Code 52510 represents prostate and prostatic urethra dilation. According to the operative report, the urologist did not perform prostate or prostatic urethra dilation in this case. Therefore, you would not report that code.

Additionally: CPT deleted code 52510 as of January 1, 2008, because this procedure never proved to be clinically effective and urologists rarely performed the procedure to relieve prostatic obstruction, Ferragamo says.

Diagnosis: You should attach ICD-9 code 598.9 (Urethral stricture, unspecified) to each of the procedures you report for this case.