Urology Coding Alert

Question: Can you help me code this case? The operative report says the pre-op diagnosis is gross hematuria and the post-op diagnosis is radiation cystitis. During cystoscopic examination the urologist saw telangiectasias at the bladder neck and many obstructing clots within the bladder. He used a clot evacuator to free the bladder of all clots. He cauterized the bladder neck telangiectasias using a roller ball electrode through a resectoscope. Then after re-inspection of the bladder, he did not view any tumors. After he removed the clots, and there was no active bleeding, the urologist removed the resectoscope. He placed a Foley catheter, draining clear urine. A rectal exam showed no rectal mass.

California Subscriber

Answer: You should bill two codes for this procedure. First, use 52001 (Cystourethroscopy for irrigation and evacuation of multiple obstructing clots) for the cystoscopic evacuation of the multiple obstructing bladder clots. Append modifier 59 (Distinct procedural service) to bypass the edit with 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands). Report 52001 as the primary operation since this is the higher-paying procedure. This evacuation procedure is a separate and distinct procedure (not an integral part of another procedure) and takes on the role as the primary procedure/operation of this session. Use ICD-9 diagnosis codes 596.8 (Other specified disorders of the bladder) for the bladder hemorrhage and 998.11 (Hemorrhage complicating a procedure).

Next, report 52214 for the fulguration at the bladder neck. Attach diagnosis code 599.71