Urology Coding Alert

Question: I need to code the following procedure for my urologist: He performed a cystoscopy using a 21 French scope that revealed a large median lobe and some friable bulbous type lesions (questionable tumors) coming off the interior portion of the bladder/median lobe of the prostate. He had noticed this area was bleeding during a prior in-office cystoscopy. Using a 24 French resectoscope, he completely resected the lesions and a large portion of the median lobe of the prostate. He then evacuated the chips using the Ellik evacuator. He was able to control all bleeding and identify the ureteral orifices prior to the resection. He resected the majority of the median lobe in the process of resecting these lesions.

Florida Subscriber

Answer: First, report 52612 (Transurethral resection of prostate; first stage of two-stage resection [partial resection]) for the transurethral resection of the prostatic median lobe. Attach 600.01 (Hypertrophy [benign] of prostate with urinary obstruction) as the diagnosis code.

Also report 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 up to 2.0 cm]) for the resection of the tumor at the bladder neck.

Diagnosis warning: The diagnosis code for this portion of the procedure is 239.4 (Neoplasms of unspecified nature; bladder) because you do not yet know the pathology of these bladder neck lesions. Remember that 239.4 is a payable diagnostic code indicating medical necessity.