Urology Coding Alert

Question: The urologist guided a 17 French cystoscope into the patient’s bladder. There was a mild bulbar stricture which was easily dilated with the cystoscope. The physician thinks we should report 52000 since he did not use a dilator. I’m leaning more toward 52281 since it does not specify the use of dilators either. What do you recommend?

Louisiana Subscriber

Answer: Begin by taking a closer look at the descriptors for the two procedures you’re considering:

• 52000 – Cystourethroscopy (separate procedure)
• 52281 – Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female.

Based on the information you provide, code 52281 is the better option. Because the descriptor states “and/or dilation,” you can report 52281 whether or not the provider performs dilation in conjunction with the calibration during a cystoscopic examination. In addition, 52281 is a much more thorough description of your provider’s work when compared to 52000. And, as every coder knows, your goal is to report the most accurate code possible for services.