Urology Coding Alert

Question: When a doctor performs a transurethral biopsy of a bladder tumor and a prostatic urethral biopsy, how should these two procedures be coded?

Utah Subscriber

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.



Answer: A cold-cup clamshell biopsy of the bladder should be coded as 52204 (cystourethroscopy, with biopsy). The same code may be used if a cold-cup biopsy of the prostatic urethra is also performed (for example, 52204 and 52204-59 [-distinct procedural service]). However, if the urologist does a transurethral resection biopsy of the prostatic urethra for deeper tissue, use 52601 (transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included])) with modifier -52 (reduced services) on the first line, and 52204-59 on the second line, because 52204 is bundled into 52601. Modifier -52 indicates an elective lesser procedure. Consider 239.4 (neoplasms of unspecified nature; bladder) for the bladder biopsy, and 239.5 (neoplasms of unspecified nature; other genitourinary organs) for the prostatic urethra.