Urology Coding Alert

Question: Once the patient was under anesthesia, my urologist inserted the tip of a flexible cystoscope into the urethra and slowly glided it up and into the bladder. My urologist examined the urethra and injected sterile saline water into the bladder to improve the view of the bladder wall. My urologist advanced the scope into each ureter, performing a ureteroscopy all the way to the upper end of the ureters where they enter the renal pelvis, and into the left renal pelvis where he discovered a lesion. My urologist inserted a biopsy instrument through the scope into kidney and biopsied the lesion for pathologic study. When the procedure was completed, my urologist withdrew the instruments and cystoscope and drained the bladder. Which code should I report for this procedure?

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Answer: You should report code 52354 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion)-LT (Left side) for this procedure. At the present time, ureteroscopy of the contralateral ureter is bundled but billable at the same encounter with a modifier. In this case also bill 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic)-RT (Right side) for the ureteroscopy of the right ureter. Some carriers will then pay for both codes.

Cystourethroscope defined: A cystourethroscope is a flexible or rigid tube with a camera at one end that a provider inserts through the urethra into the bladder to examine the urethra and urinary tract.