Urology Coding Alert

Question: My urologist performed a bladder biopsy at the same time another physician performed a colostomy closure. After my urologist finished the bladder biopsy and left the operating room, he was called back in to perform a ureteral dissection, or as he documented it, "pelvic exploration with dissection of left and right ureter from fibrotic pelvic mass, posterior vesicle dissection and closure of cystotomy." How should I code this?

Utah Subscriber

 Answer: Use 50715 (Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis) to report ureteral dissection, and append modifier -50 (Bilateral procedure) to indicate that the urologist dissected both the left and right ureters. Because the ureters are on separate sides of the body, dissection of both ureters is considered "bilateral."

 For the bladder biopsy, you will need either 52204 (Cystourethroscopy, with biopsy) or 52224 (Cystourethro-scopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy) depending on whether the documentation indicates that the urologist removed a minor lesion at the time of the biopsy. And if the posterior bladder dissection was a significant portion of the operation, you may report 51080-52 (Drainage of perivesical or prevesical space abscess; Reduced services), 44005 (Enterolysis [freeing of intestinal adhesion] [separate procedure]), or unlisted-procedure code 53899 (Unlisted procedure, urinary system), depending on the documentation. The urologist also appears to have repaired a bladder laceration. If this is the case, report 51860 (Cystorrhaphy, suture of bladder wound, injury or rupture; simple) or 51865 ( complicated).