Urology Coding Alert

Question: Below is my practitioner’s surgical note. Can 52281 be billed for this, or would this be 52000 alone? The urethral dilation was done after the cystoscopy, and the descriptor for 52281 makes it sound like the dilation needs to be done as part of the cystourethroscopy, before the scope is removed.

Procedure: The patient was prepped and draped in usual sterile fashion. On initial pelvic exam, the distal meatus was closed with some scar tissue. I was able to introduce the 22 French cystoscope with gentle constant pressure. Once inside the bladder, I performed full cystoscopy and saw no bladder lesions, only mild trigonitis. I then carefully watched the urethra as I pulled the cystoscope out and the only area of stricture was at the very distal meatus. I then used female sounds to dilate up to 26 French. I then placed an 18 French Foley catheter, instilled 10 cc into the balloon. Findings: Short circumferential ring stricture at the very distal urethral meatus, mild trigonite’s but no bladder lesions.

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Answer: The correct coding would depend on the reason for the service. “I am only assuming, based on the context of trigonitis and bladder lesions, that the focus of the service was a diagnostic study and not a therapeutic service. If that is the case, then only 52000 [Cystourethroscopy (separate procedure)] would be coded, as the dilation of the stricture was done as a means to complete the diagnostic study, not as a therapeutic service,” says John Piaskowski, CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey and surgical coding consultant at Memorial Care Health System in Huntington Beach, California.

The stricture complicated the provider’s access to advance the cystoscope and also to safely remove it after the procedure. Per coding standard, you wouldn’t code for services that are inherent to completing the main procedure. The Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative Manual (NCCI) chapter 7, Section C-15 further clarifies this by stating, “When urethral catheterization or urethral dilation is necessary to complete a more extensive procedure, the urethral catheterization/dilation is not separately reportable.”

Also, the stricture appears to be an incidental finding, and incidental services are not reported. “If the assumption I made is wrong and the ring stricture or other related symptoms were the reason for the exam, then code only 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]. Keep in mind that unless there is a physician order for a diagnostic study, you would not normally report a code for one after a procedure. This is usually only performed after a procedure for prophylactic reasons, such as checking for efficacy/completion of the dilation or for systemic stability or to rule out iatrogenic (surgery related) injuries,” says Piaskowski.