Wiki Your thoughts...52281 or 52265

[umcanes4]

Good morning! I wanted to run a procedure by everyone and see what your thoughts are. We are having 2 different codes regarding the dilation being argued for this

Pre-Procedure Diagnosis:hematuria, luts.

Post-Procedure Diagnosis:Same as pre-procedure diagnosis.

Procedure Name:cystoscopy, bladder biopsy, urethral dilation.

Sedation / Anesthesia:Appropriate sedation/anesthesia was achieved using MAC.

History:Pt with hematuria and luts. CT unremarkable GU tract. Here to complete workup. We discussed the risks/benefits/alternatives/indications for the procedure. Risks include but not limited to bleeding, infection, pain, need for repeat procedures, injury to the surrounding structures. All questions answered.

Procedure Findings:tight urethra -- dilated
moderate bladder trabeculations
inflammatory changes noted within bladder -- biopsy done
glucose elevated preop -- we have discussed with her extensively need to follow up with her primary care.

Procedure Description:After informed consent was received patient was brought to the operating room and placed in a supine position. Anesthesia was induced. Patient was placed in a dorsal lithotomy position and genitals were prepped and draped in a standard fashion. Appropriate time out was performed.
Cystoscopy was inserted into the urethra.
Urethra was tight and unable to pass cystoscope. Urethra dilated to 26french.
Once inside the bladder we surveyed the bladder with 30 and 70 degree lens. Bladder with moderate trabeculations.
Ureteral orifices orthotopic with clear efflux.
There were no abnormal papillary lesions identified. There were inflammatory changes in the left wall that was biopsied and fulgurated.
Once our procedure was complete all instrumentation was removed. We injected viscous lidocaine and gave a B&O suppository. Patient was placed back into supine position. Anesthesia was reversed and transferred to recovery room in stable condition.

Path: URINARY BLADDER, LEFT WALL BIOPSY: chronic inflammation.

We have 1 coder stating 52281 because he dilated the urethra.

Another coder stating 52265 because the path states inflammation of bladder and states the bladder is the one that was being dilated.

I appreciate any and all your thoughts and feedback thanks and have a great day!

 

[emcee101]

There is no documentation that supports coding for 52265, which is a hydrodistention of the bladder. The doctor would have to note that several hundred CCs of irrigation fluid was instilled into the bladder, allowed to sit for several minutes, and the the bladder was re-entered and surveyed again. This procedure is done for interstitial cystitis which is also not identified.

There is documentation of 52281, but I would kindly refer you to CPT code 52204 - bladder biopsy, which it seems is the main procedure performed by your doctor. The two codes (52204 and 52281) cannot be billed together due to CCI edits, but you should see higher reimbursement due to higher RVUs for 52204, which is also the more accurate code choice in my opnion.

Hope this helps, and any further thoughts would also be appreciated.

MJC

 

[umcanes4]

Thanks MJC!! I think all of us were so wrapped up in arguing our reasons for the 52281/52265. Ohhhh, is it Friday yet?!?! Thanks again. Your information helped and was greatly appreciated.