You Be the Coder: Reporting Bladder Hydrodistention- Published on Sat, Jul 01, 2006 Updated on Wed, Oct 01, 2014
Reviewed on May 27, 2015
Question: How should I code for bladder hydrodistention for a patient with interstitial cystitis?
Answer: The code you’ll report depends on the type of anesthesia provided to the patient. For a cystoscopy and bladder hydrodistention using general or spinal anesthesia, you should report 52260(Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction [spinal] anesthesia). If the urologist provided local anesthesia, use 52265 (... local anesthesia).
Don’t forget the diagnosis: Use 595.1 (Chronic interstitial cystitis) for the urologist’s diagnosis of interstitial cystitis. For ICD-10, report N30.10 (Interstitial cystitis [chronic] without hematuria) or N30.11 (Interstitial cystitis [chronic] with hematuria).
Bonus: If the physician also instills a medication at the same session, you can separately report that service using 51700 (Bladder irrigation, simple, lavage and/or installation).