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cysto bladder biopsy and ureteroscopy 52351, 52204

Tanesha Posted Tue 03rd of September, 2019 17:02:09 PM
Edit with 52351 as comprehensive, but it seems more work is done with the biopsy. Am I stuck only reporting 52351? OP Excerpt: Dome of the bladder. We used sterile water and a biopsy forceps. These two areas were biopsied and completely removed. We used a Bugbee at a setting of 30 to cauterize the biopsy sites for hemostasis. I next performed flexible ureteroscopy of the reimplanted ureter. This showed no abnormalities within the ureter or upper tract collecting system. There were no tumors seen. A left retrograde pyelogram was performed. No filling defects were seen. We switched over to the rigid cystoscope. A right retrograde pyelogram was performed.
SuperCoder Answered Wed 04th of September, 2019 10:23:30 AM


Thanks for your query.

Code 52351 suggests that the provider performs a diagnostic cystourethroscopy, the inspection of the interior of the bladder, the urethra, prostatic urethra, and ureteric openings using a cystoscope passed through the urethra and into the bladder, and performs a ureteroscopy (inspection of the ureters) and/or a pyeloscopy (inspection of the renal pelvis).

The code description didn’t describe about the biopsy being performed. In this scenario, the provider performed biopsy. Code 52204 includes biopsy.

Code 52351 and 52204 can be billed together with a modifier 59 with code 52204.

Please feel free to ask if you have any questions.

Hope this helps.


Tanesha Posted Wed 04th of September, 2019 10:47:01 AM
Ok, thank you for your response.
SuperCoder Answered Thu 05th of September, 2019 02:40:26 AM

Thank you, happy to help.

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