Urology Coding Alert

Question: I am coding for biopsy of a ureteral stump that seems to have grown into the bladder lumen. I don’t see this as a bladder biopsy since the biopsy was only taken from within the ureter. Would code 52354 be appropriate?

Mississippi Subscriber

Answer: Yes, code 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion) is probably the most appropriate, depending on your specific documentation. 

Here’s why: The CPT^® index points you to 52354 for a biopsy of the ureter, making this the most appropriate choice.