Urology Coding Alert

Question: The doctor's slip states: "cysto, bilateral ureteroscopy, bilateral stents, biopsy and laser ablation of left renal lesion and laser ablation of right ureteral lesion." How would I report these procedures for a Medicare patient?

Alabama Subscriber

Answer: For this scenario you should report the following:

• 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. Append modifier-50 (Bilateral procedure) since your urologist performed the same procedure on both sides but for different lesion locations -- one in the renal pelvis and one in the opposite ureter.
• 189.1 (Malignant neoplasm of renal pelvis) and 189.2 (Malignant neoplasm of ureter) as the diagnosis codes with 52354-50.
• 52332-50 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]; bilateral procedure) for the bilateral JJ stent placements.