Urology Coding Alert

Question: When a doctor performs a transurethral biopsy of the bladder and a transurethral biopsy of the prostatic urethra to map the bladder and posterior urethra for carcinoma in situ, how should I code these two procedures?

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Answer: You should code a cold-cup "clamshell" biopsy of the bladder as CPT 52204 (Cystourethroscopy, with biopsy). The same code may be used if you perform a cold-cup biopsy of the prostatic urethra (for example, 52204 and 52204-59 [Distinct procedural service]).
 
But if the urologist does a transurethral resection biopsy of the prostatic urethra for deeper tissue, use 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]) with modifier -52 (Reduced services) on the first line and 52204-59 on the second line because NCCI bundles 52204 into 52601.
 
Modifier -52 indicates an elective lesser procedure. Consider linking the procedures to 239.4 (Neoplasms of unspecified nature; bladder) for the bladder biopsy and 239.5 (Neoplasms of unspecified nature; other genitourinary organs) for the prostatic urethra.
 
Use 52612 (Transurethral resection of prostate; first stage of two-stage resection [partial resection]) for the deeper transurethral biopsy of the prostate. In this case you would code 52612 for the deeper core biopsy of the prostatic urethra and 52204-51 (Multiple procedures) for the superficial bladder mucosal biopsy. NCCI doesn't bundle 52612 and 52204, so modifier -59 is unneeded.