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Biopsy bladder and prostatic urethra

  1. Default Biopsy bladder and prostatic urethra
    Medical Coding Books
    Cpt 52204 is bundled into 52601. The biopsies were done in 2 different sites during the post op period. Should a modifier 59 be used to unbundle the cold cup biopsy?

    After the bladder has been fully visualized, cold cup biopsies were taken initially of the right lateral wall, which was the area of the possible urothelial abnormality followed by posterior wall, trigone, and left lateral wall. Each biopsy site was fulgurated witha Bugbee electrode. Hemostasis was assured.
    At this point the cystoscope was removed and replaced with a #25 continuous flow ACMI resectoscope.
    At this point TUR biopsies were taken of the remaining urethra. Mucosa was resected circumerentially. Hemostasis was then assured with a resectoscope.

    The pat had a TUR 2 months earlier and is back during post op period

    52601 mdf 76 - TUR
    52204 mdf 59/79 - Cold cup biopsy

  2. #2
    Albany, New York
    Was the TUR of the prostate a planned two stage procedure?

    If so, your CPT for this session would be 52614 and it is not bundled with 52204.
    Karen Maloney, CPC
    Data Quality Specialist

  3. Default
    I hope this helps.

    Indications: The patient is status post TURP, which demonstrated a probable TCC of the prostatic urethra. Therefore the pat was brought back to the OR for TUR biopsies of the prostatic urethra and random biopsies of the bladder.

  4. #4
    Albany, New York
    Do you have access to a Coders' Desk Reference?

    I think 52204 will cover both procedures.
    Karen Maloney, CPC
    Data Quality Specialist

  5. #5
    Albany, New York
    Disregard my previous statement.

    In re-reviewing your first message, you need to look at codes
    52214--52240 depending on size of bladder lesions that were fulgurated following biopsy.

    Please let me know what you come up with.
    Karen Maloney, CPC
    Data Quality Specialist

  6. Default
    If fulgaration is done after biopsy to stop the bleeding you wouldonly code the biopsy, and not the fulgaration.

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