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Urology Coding Alert

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52300 or No 52300? That Is the Ureterocele Question

Published on Mon Jan 17, 2011

Question: My urologist performed a cystoscopy, transurethral incision of an orthotopic ureterocele, ureteroscopy, and a double J stent placement. I have drawn a blank on how to repot the ureterocele incision. Here is the doctor's note: "A 24 resectoscope was introduced without any difficulty. Subsequently I went ahead and then used the Collin knife on the resectoscope and using pure cutting, I went ahead and made two incisions in the distal ureter laterally and inferior almost at the level of the floor of the bladder in the lateral and the medial aspect of the ureteral opening. The ureterocele opened up nicely. The flap of the tissue was raised up and this appeared to collapse well." How should I report this?Answer: For this scenario, you should report the following codes: 52351 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic) for the cystourethroscopy and ureteroscopy52300 (Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral [...]
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