Cystoscopy and Ureteroscopy Procedures

Cystoscopy and ureteroscopy procedures will be discussed in this episode of “Spotlight on CPT”.  These procedures are similar as they both begin with the insertion of a scope through the urethra and into the bladder.  

When coding procedures that involve the urinary system, terminology is vital.  Organs have similar names and it is important for accurate coding that we differentiate between the terms correctly.  So let’s start this discussion with an overview of the urinary system beginning externally.
 
    1 Urethra
    Leads to
    1 Bladder
    Leads to
    2 Ureters
    Leads to
    2 Kidneys 


And the Urinary System looks like this:

Source: https://www.yourdictionary.com/urinary-system

When a cystoscopy or cystourethroscopy is performed, the catheter is inserted in the urethra and then into the bladder.  Inspection occurs there.  This is often done for patients that have bladder neoplasms.  Biopsies can be taken or fulguration/resection which can destroy/remove abnormal tissue.  These destruction or removal codes are based on the location and size of the lesion.  Biopsies taken from the same area that is being destroyed, in the same encounter, are not separately coded.  However, it the biopsy comes from a different area of the bladder, it can be coded with an appropriate modifier.

Ureteroscopy procedures may include a pyeloscopy as well.  A code from this section could be assigned for a ureteroscopy with lithotripsy and double-J stent insertion with a combination code of 52356.

If one is not careful, it would be easy to be in the wrong section of the CPT manual when assigning codes.  This could result in code 52204 cystourethroscopy with biopsy being assigned instead of 52354 for cystourethroscopy with ureteroscopy with biopsy. 

Now, light has been shed on coding cystoscopy and ureteroscopy procedures.

 

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.