Urology Coding Alert

Question: One of my urologists is going to do a cysto/direct vision internal urethrotomy, evacuation of clots, and fulguration of the prostate on a patient who had a TURP done by another doctor 10 years ago. I'm not sure how to code this. I know 52276 is the cysto/IU and 52001 is the clot evacuation, but I don't know which code to use for the prostate fulguration. I am also not sure whether I should use a modifier and unbundle 52276 and 52001. How should I report this procedure?


New York Subscriber


Answer: The first code you should report is 52001 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots). This code represents the cystoscopy and irrigation of the "multiple and obstructing clots." You should use this as your primary operative procedure because it has the higher relative value. You should, in fact, append modifier 59 (Distinct procedural service) to unbundle this procedure from the other two and to indicate that this procedure was distinctly separate from the fulguration and stricture treatment.

The second code you should report is 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra or periurethral glands) for the fulguration of the prostatic fossa. Attach modifier 51 (Multiple procedures) to 52214 because your urologist performed multiple procedures during the same operative session.

Last, report 52276-51 (Cystourethroscopy with direct vision internal urethrotomy; multiple procedures) for the treatment of a pre-existing stricture.

Diagnosis: Your diagnoses may include 599.89 (Other specified disorders of urinary tract) for a diagnosis of gross hematuria, 596.8 (Other specified disorders of bladder) for clot retention, and 598.9 (Urethral stricture, unspecified).