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Urology Coding Alert

Reader Question:

52354: Attach Modifier 50 For Different Lesions

Published on Fri Jul 15, 2011

Question: My doctor documented the following procedure "cysto, bilateral ureteroscopy, bilateral stents, biopsy and laser ablation of a left renal pelvic malignant lesion, and laser ablation of a right malignant ureteral lesion." How should I report this procedure?Colorado SubscriberAnswer: First, report 52332-50 (Cystourethroscopy, with insertion of indwelling ureteral stent [eg, Gibbons or double-J type]) forthe bilateral JJ stent placements.Additionally: You should report 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion) for the biopsy and ablation of the lesions. Since the urologist performed the same procedure on both sides for lesions in different locations -- one in the renal pelvis and one in the opposite ureter -- you should append modifier 50 (Bilateral procedure) to 52354.The diagnoses you should report for this case would be 189.1 (Malignant neoplasm of renal pelvis) and 189.2 (Malignant neoplasm of ureter).
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