Urology Coding Alert

Question: A patient's pre-procedure diagnosis was meatal irregular-appearing lesions involving the meatus at the junction with the urethra more prominent on right side and involving two-thirds of the urethral margin from dorsal to ventral. The urologist performed flexible cystourethroscopy. A sliver of skin on the right side was excised and a meatoplasty was done by approximating the urethral edges. On the left side, she saw a smaller lesion ventrally near the junction of the urethral epithelium and the glans. This was fulgurated with a Bugbee electrode. Would code 53460 be correct for this procedure?

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Answer: During the service represented by 53460 (Urethromeatoplasty, with partial excision of distal urethral segment [Richardson type procedure]), the surgeon enlarges the meatal opening by making an incision to treat meatal stenosis (or narrowing), and reconstructs any part of the urethra near the meatus. Code 53460 would be appropriate.

Because the surgeon also performed fulguration of the urethral lesions, you may add code 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or peri-urethral glands).

With code 52214, the urologist uses a cystoscope to inspect the interior of the bladder, the urethra, prostatic urethra, and ureteric openings. The cystoscope is passed through the urethra and into the bladder. It is a common diagnostic procedure for conditions ranging from urinary tract infections and stress incontinence, to the follow up of bladder cancer treatment. This specific procedure includes fulguration, which is the introduction of an electric current to eradicate tissue that is diseased.