Ob-Gyn Coding Alert

That said, you technically could bill 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) for this prophylactic procedure, but keep in mind that this code was never added to CPT^® for this purpose. The clinical vignette describing the physician work used to add the code to the CPT^® book is as follows:

Turn on video monitors. Be sure all personnel are safely in lead aprons. Place flexible cystoscope. Inspect entire bladder. Locate ureteral orifice. Order indigio carmine to be administered IV and wait 5 minutes for the efflux. Insert flexible wire up the ureter and confirm fluroscopically. Pre irrigate an open ended ureteral catheter and advance over the wire. Remove wire. Inject the ureteral catheter with contrast and obtain radiographs or digital images. Assess the images for completeness and possibly reinject. Remove catheter and reinspect bladder for any damage. Drain bladder and remove endoscope.

Please be sure that your provider is documenting this part of the procedure completely — and it would also be helpful to add a note as to why it is medically necessary for this patient.

If you bill this code, you should not append modifier 50 (Bilateral procedure) because the basic procedure is an examination of the bladder and urethra (cystourethroscopy), which are not paired organs. The work relative value units (RVUs) assigned take into account that it may be necessary to examine and catheterize one or both ureters.

So, as a coder, you must ask yourself: “Is a diagnostic cystourethroscopy being performed and documented as such?” A statement like “scope placed” will not work, and there should be some description of the bladder and urethral findings.

If you do bill 52005, your diagnosis code will have to be Z40.8 (Encounter for other prophylactic surgery) unless you can also report an underlying medical need for the patient (such as previous surgical injury, presence of adhesions, etc., to further back up the need). Pull whatever details you can from the operative report and medical record to explain what your ob-gyn did and why.

Linking the diagnosis for the reason for the gyn surgery will get you a denial for medical necessity. If you look at any surgical text, you will clearly see that identification of the ureters is integral to any gyn procedure, so you may find that most payers consider the use of prophylactic ureteral catheters to prevent damage to be part of the procedure. Even the American College of Obstetricians and Gynecologists (ACOG) coding manual has in the past stated that insertion of stents and catheters during a procedure is included.