Urology Coding Alert

Question: Our doctor did an excision and fulguration of meatal condyloma. The lesion was 2 cm in size. He used a 4-0 chromic suture to evert the mucosa to minimize the risk of stenosis in the future. He then did a urethroscopy to the sphincter that demonstrated no evidence of any further lesions in the fossa navicularis or in the urethra consistent with condyloma. How should I report this procedure?

Pennsylvania Subscriber

Answer: You should report 53260 (Excision or fulguration; urethral polyp(s), distal urethra) for the excision and fulguration of the urethral meatal condylomata. Assign diagnosis code 078.11 (Condyloma acuminatum).

Then, report 52000 (Cystourethroscopy [separate procedure]) for the urethroscopy. Use 078.11 again, along with V65.5 (Person with feared complaint in whom no diagnosis was made).