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May 2016 page 12 Coding Brief: Reporting Cystourethroscopy with Fulguration Procedures and Bladder Tumor Resections Current Procedural Terminology (CPT®) codes 52204-52240 are used to report cystourethroscopy with biopsy fulguration and/or bladder tumor resection.
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Use CPT 52001 -59 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots; distinct procedural service) for the cystoscopy and clot evacuation.
52214: Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands.
Blood clots are removed using suction through the telescope. Once the bladder is free of clots, it may then be possible to identify the cause of any bleeding and, if appropriate, this will be treated at the same time. The operation takes approximately 30–60 minutes.
The Coding Clinic for ICD-9-CM was established in 1984 to help everyone who had an interest and dedication in improving the accuracy and uniformity of medical record coding. The newsletter was created to provide coding advice, official coding decisions, and news related to the use of ICD-9-CM.
Fulguration is the process of removing abnormal bladder tissue with the use of a specialized tool. During fulguration, one of the commonly used tools, a resectoscope, is inserted through the urethra, into the bladder. It is inserted in a similar way to a foley catheter or cystoscope.
Yes, on the CCI it has a "1", you can bypass with a '59' modifier IF you have enough documentation to support the procedure.
Blood clots in urine aren't commonly present and are a special type of hematuria. When present, though, they may indicate certain serious health issues such as bladder cancer, kidney injuries, and others. If you see blood in your urine, it's advisable to schedule an appointment with your doctor.
Hydrogen peroxide solution for manual bladder irrigation can improve the efficiency of bladder blood clot evacuation. This is a simple and effective option for managing bladder clot retention.
Blood clots within the bladder postoperatively can be removed by a number of methods, including hand irrigation through a Foley catheter or cystoscopic evacuation with an evacuation device.
ICD-10-PCS will be the official system of assigning codes to procedures associated with hospital utilization in the United States. ICD-10-PCS codes will support data collection, payment and electronic health records. ICD-10-PCS is a medical classification coding system for procedural codes.
A combination code is a single code used to classify two diagnoses, a diagnosis with an associated secondary process (manifestation) or a diagnosis with an associated complication.
The Coding Clinic is to be used as an official resource when the classification and the guidelines do not provide direction.
The AHA Coding Clinic on ICD-10-CM/PCS can be accessed at the AHA website. So be sure to check that out, as a paid subscription is required, but definitely worth the fee. You can, however, submit ICD-10-CM and PCS coding questions for free via the online portal, so that is also a great option for coding and even CDI professionals ( https://www.codingclinicadvisor.com/ Home/HelpCenter).
The AHA Coding Clinic is not just for hospital coding; their guidance often applies to all the different healthcare settings, even physician offices and clinics. With this new release of Coding Clinic, there are some steps that I advise HIM, coding, and CDI professionals to take:
Revised March 24, 2021
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