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Ureteral stump that has grown into bladder

Nancy Posted Sun 24th of November, 2019 17:03:44 PM
Would 52354 be appropriate? Since biopsy was taken from bladder because stump grew into it. Not really a bladder biopsy I would think. Not sure how to code. Thanks.
SuperCoder Answered Mon 25th of November, 2019 07:54:55 AM


Thanks for the question.

As per the documentation available, code 52354 appears to be appropriate. The CPT® index directs towards code 52354 for biopsy of bladder or ureter.

Code 52354 suggest that the provider inserts the tip of a flexible or rigid cystoscope into the urethra and slowly glides it up and into the bladder. The camera attached to the cystoscope allows images of the bladder to be viewed on a monitor. The provider examines the urethra and injects sterile saline water into the bladder to improve the view of the bladder wall. The provider may exchange the cystoscope for a ureteroscope, or he may have performed the bladder inspection with a ureteroscope, which is smaller than a cystoscope. The provider advances the scope into each ureter, performing a ureteroscopy all the way to the upper end of the ureters where they enter the renal pelvis, and into the renal pelvis or calices, where he discovers a lesion. He inserts a biopsy instrument through the scope into kidney and excises the lesion for pathologic study or inserts a specialized device to deliver high–frequency electric current to the lesion, which burns and disintegrates the lesion. When the procedure is complete, he withdraws the instruments and cystoscope and drains the bladder.

Hope this helps.


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