Urology Coding Alert

Question: My urologist did an endoscopic examination (cystoscopy) of a continent abdominal intestinal-urinary pouch via the contiguous intact urethra (urethra-intestinal continent diversion). How should I code this? This patient is insured under Medicare.
      
Indiana Subscriber Answer: For this endoscopy, you should report the following codes:

  CPT 44385 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the endoscopy of the abdominal intestinal diversionary pouch.

  CPT 52000-52 (Cystourethroscopy [separate procedure]) for the endoscopy of the urethra. Append modifier -52 (Reduced services) to indicate that you only examined the urethra and no other structure such as the bladder.
 
You can use the above coding for either Medicare or commercial carriers.