I'd think I would go with CPT 52881 based on what you have listed.

But here's some info on this..


Coding Alert
Reader Questions: Choose BNC Dilation Code Based on Op Note Details





Question: Can I use 52281 for a bladder neck constriction dilation?

Florida Subscriber

Answer: Your coding for a bladder neck constriction dilation will depend on where and how your urologist performed the dilation.

Option 1: If your urologist did the dilation of the bladder neck and also a cystoscopic examination, you can report 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female). Use this code whether he did the dilation and cystoscopy in the office under local anesthesia or in the hospital operating room (OR) with spinal or general anesthesia.

Option 2: If your urologist performed the dilation of the bladder neck only, without cystoscopic examination and under local anesthesia, you may choose from the following codes:

• 53600 (Dilation of urethral stricture by passage of sound or urethral dilator, male; initial) and 53601 (…subsequent)

• 53620 (Dilation of urethral stricture by passage of filiform and follower, male; initial) and 53621 (…subsequent).

Option 3: If your urologist performed a bladder neck dilation in the OR under general or spinal anesthesia, use 53605 (Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction [spinal] anesthesia).