Question: My urologist removed a patient's suprapubic (SP) tube and through the suprapubic tract performed an endoscopic (cystoscopic) examination and bladder stone and stent removal. He then placed a flexible ureteroscope through the suprapubic tract and into the renal pelvis to basket and remove two stones. He examined the renal pelvis and the entire course of the ureter. He placed a double J stent in the ureter and replaced a new SP tube. Does the fact that the doctor performed the cystoscopy through the SP tube tract change the coding for this case?
Answer: You should report the appropriate cystoscopic and endoscopic codes for this case. There is nothing in the CPT® descriptor that defines the access point or method of a cystoscopy.
You should report the following: