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Urology Coding Alert

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When Can You Separately Report Ureteral Dilation?

Published on Fri Jun 17, 2011

Question: My doctor performed a cystoscopy, dilatation of the ureter, right retrograde pyelogram, ureteroscopy, and placement of a right double-J stent. I need help coding the procedures. Is the dilation bundled into the other procedures?Alaska SubscriberAnswer: If the dilation of the ureter is to facilitate the passage of an instrument such as a ureteroscope through a narrow but otherwise normal ureter, this dilation becomes an integral part of the procedure, and you should not bill it separately. Bill only for the ureteroscopy using 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic).Alternative: If the dilation is performed because of the presence of a ureteral stricture, then bill a ureteral dilation code -- 52341 (Cystourethroscopy; with treatment of ureteral stricture [eg, balloon dilation, laser, electrocautery, and incision]) or 52344 (Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision]) -- with the diagnosis of ureteral stricture (593.3, Stricture or kinking [...]
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