Urology Coding Alert

Question: A patient with interstitial cystitis presented to the ambulatory surgery center (ASC) for a cystoscopy with hydrodistension. After undergoing general anesthesia, the urologist inserted a cystoscope into the urethra for visualization of the bladder and a urethral stricture. The surgeon filled the bladder to 400 cc and subsequently drained it, repeating the process again once over. Following drainage of the bladder and placement of a feeding tube, the surgeon injected a specialty cocktail for treatment of interstitial cystitis that included heparin, lidocaine, sodium bicarbonate, and Elmiron. What’s the CPT^® coding breakdown?

Arizona Subscriber

Answer: You’ve got a few components of this procedure to consider: the placement of the cystoscope for visualization of the urethra and bladder, the repeated dilations of the bladder, and the bladder instillation of the specialty cocktail.

A bladder scope, which can be identified by the terms either “cystoscopy” or “cystourethroscopy,” can be found within the CPT^® Index under the term “cystourethroscopy.” In this clinical encounter, the cystourethroscopy is performed for the purposes of bladder dilation, or hydro-distention. The components of the operative report involving the visualization of the stricture and the subsequent two 400 cc dilations of the bladder encompass this portion of the surgery. In the CPT® Index, looking up Cystourethroscopy ? Dilation? Bladder will direct you to CPT^® codes 52260 (Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia) and 52265 (… local anesthesia). Since the urologist documented general anesthesia administration, you should opt for code 52260.

Next, you must account for the tube placement for the specialty cocktail injection into the bladder for treatment of the patient’s interstitial cystitis. This portion of the procedure, also known as a bladder instillation (of medications), can be found by searching Instillation ? Drugs ? Bladder in the CPT^® Index, leading you to 51700 (Bladder irrigation, simple, lavage and/or instillation). As you can see within the code description, this includes a simple bladder irrigation, but since the bladder was already irrigated with the dilation portion of the service, you only need to consider the bladder instillation coding. You’ll see that this code pairing produces no National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits. Therefore, you can report codes 52260 and 51700 together without a modifier.