Urology Coding Alert

Question: A patient underwent hydrodistention under general anesthesia for treatment of interstitial cystitis. During the same session, the urologist cauterized the trigone. How should I report this procedure?

California Subscriber

Answer: You should first report CPT 52260 (Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction [spinal] anesthesia) for the hydrodistention. Next, report 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) for the cauterization of the trigone.

Don't miss: You need to append modifier 59 (Distinct procedural service) to 52214 because the Correct Coding Initiative (CCI) bundles 52214 with 52260. You can, however, override this bundle in certain clinical circumstances, as in this case.

Your diagnosis coding will help justify using modifier 59. Report 595.1 (Chronic interstitial cystitis) along with 52260 and 596.7 (Hemorrhage into bladder wall) with 52214.