Urology Coding Alert

Answer: A cold-cup clamshell biopsy of the bladder should be coded as 52204 (cystourethroscopy, with biopsy). The same code may be used if a cold-cup biopsy of the prostatic urethra is also performed (for example, 52204 and 52204-59 [-distinct procedural service]). However, if the urologist does a transurethral resection biopsy of the prostatic urethra for deeper tissue, use 52601 (transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included])) with modifier -52 (reduced services) on the first line, and 52204-59 on the second line, because 52204 is bundled into 52601. Modifier -52 indicates an elective lesser procedure. Consider 239.4 (neoplasms of unspecified nature; bladder) for the bladder biopsy, and 239.5 (neoplasms of unspecified nature; other genitourinary organs) for the prostatic urethra.