Urology Coding Alert

Question: My urologist prepped and draped the patient in a normal sterile fashion. He inserted a 26-French resectoscope sheath and pan cystourethroscopy. The patient had 2.5 cm papillary tumor covering the left trigone, left ureteral orifice. Using a loop electrode, my urologist performed a transurethral resection of the bladder tumor and left ureteral orifice down to a normal appearing left distal ureter and into deep muscle. He used spot electrocautery for hemostasis. He used an Ellik irrigator. Reinspection revealed no remaining chips, perforations, or bleeding. Next, my urologist placed an 18-French Foley catheter. Clear efflux was noted. In the recovery room, an hour later, 40 mg of mitomycin was placed into the bladder to dwell for one hour, and then the Foley catheter was removed. The patient will follow up in two weeks in the office. What code should I report for this OR procedure? My colleague says I should report both 52235 and 52355, but I do not believe 52355 is appropriate. I think 52235 is the correct code. Can you settle our debate?

AAPC Forum Member

Answer: You are right on this one. You should just report code 52235 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)) on your claim. Code 52355 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor) is not appropriate in this case because it involves a ureteroscopy, which your urologist did not perform, according to his documentation.

Also, if your surgeon performs the bladder instillation of the Mitomycin, you should report 51720-XU (Bladder instillation of anticarcinogenic agent including retention time). Modifier XU (Unusual non overlapping services…) is needed to unbundle the procedure-to-procedure (PTP) National Correct Coding Initiative (NCCI) edit with 52235 and receive payment for both codes.