Urology Coding Alert

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Periurethral Cyst Removal

Question: Our physician did a cystoscopy with a trans-vaginal removal of a periurethral cyst for a female patient. The cyst was drained and then the cyst wall was excised. The cyst bed was sutured with deep sutures. How should I code this?

Florida Member

Answer: If your urologist performed this cyst removal via a vaginal incision and approach, report 57135 (Excision of vaginal cyst or tumor) for the drainage and excision of the cyst. You should also bill for the cystoscopic examination using 52000 (Cystourethroscopy [separate procedure]). 

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