Urology Coding Alert

Question: The patient has prostatitis and massive BPH. The urologist performed a cystourethroscopy with sounding. He documented the following: Because of the small size of the urethra a #8 French Wolf ureteroscope was prepared and used for insertion into the urethra. The urethra was sounded to #23 French. The penile, bulbous, and membranous urethra were normal. The prostatic urethra looked very inflamed, and when the doctor entered the prostatic urethra, it measured about 70-mm in length and had bolus edema and a small median bar. Physician advanced into the bladder. The ureters were in the A position and of stadium configuration. There were grade II trabeculations. There was no neoplasia or erythema seen in the bladder. All of the inflammation was centered in this giant prostate. What is the proper code for this procedure?

Oklahoma Subscriber

Answer: When the physician puts in a male sound, it is called calibration. The urologist calibrates to be sure that the urethra will accept a certain sized instrument for inspection of the urethra and bladder -- in other words, the doctor is checking to see if he can easily pass the instrument. However, that in and of itself doesnt warrant a special charge.

While the descriptor for 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) says calibration/dilation, that is not the proper code unless the patient has a stricture. In this case, there is no mention of a stricture. The only code you can really bill in the scenario you describe is 52000 (Cystourethroscopy [separate procedure]).

Reasoning: Primarily, 52000 is the correct CPT code because there is no mention of a urethral stricture, and even though the code descriptor for 52281 mentions calibration, this refers to calibration of a stricture, not the caliber of a normal urethral lumen. Otherwise, every time your physician passed a urethral sound prior to a cystoscopic examination, you may be tempted to bill 52281, but that isnt what that code was created to represent. The measurement of the intraurethral diameter is really just part of the cystoscopic examination.

In this case, because of the small size of the urethra, the urologist used a ureteroscope of small caliber to examine the bladder and urethra. No matter what instrument the urologist uses the procedure is still a cystourethroscopy -- which means code 52000.