👩🏾‍⚕️CPT 52354 - Cystourethroscopy with Ureteroscopy and/or Pyeloscopy; with Biopsy and/or Fulguration of Lesion

Full CPT Descriptor: Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of lesion (ureteral catheterization is included)

📋 Procedure Overview

CPT 52354 describes a combined diagnostic and therapeutic endoscopic procedure in which the surgeon passes a rigid or flexible ureteroscope transurethrally through the bladder and into the ureter and/or renal pelvis (pyeloscopy) to perform one or both of the following interventions on a lesion of the upper urinary tract:

Biopsy - Tissue sampling of a ureteral or renal pelvic lesion using cup biopsy forceps, brush biopsy, or cold-cup biopsy technique to obtain histopathologic material.
Fulguration - Electrocoagulative or laser-based ablation/destruction of a urothelial lesion, typically used for small, papillary low-grade tumors, carcinoma in situ (CIS), or bleeding vessels/lesions not amenable to excision.

This code is most commonly associated with the evaluation, diagnosis, and conservative management of upper tract urothelial carcinoma (UTUC), including malignancies of the renal pelvis and ureter. It is also used for benign ureteral polyps, granulomatous lesions, inflammatory strictures with associated tissue abnormalities, and hematuria workup where a ureteral or pelvic lesion is identified and sampled.

Because ureteroscopy inherently requires placement of a ureteral catheter for access and visualization, ureteral catheterization is explicitly bundled into this code and may not be billed separately. The code captures both biopsy and fulguration within the same session — meaning if both are performed on the same lesion or multiple lesions during one encounter, 52354 is reported only once per ureter/session.

⚙️ Procedural Mechanics

The procedure typically proceeds as follows:

Cystoscopy is performed first under general or spinal anesthesia — bundled, cannot report 52000 separately.
The bladder is inspected; the ureteral orifice(s) are identified.
A guide wire is advanced under fluoroscopic or direct vision into the ureter and kidney.
A flexible or rigid ureteroscope is passed over the wire into the ureter and/or renal pelvis; the approach is via natural or artificial opening (endoscopic).
The lesion is identified — urothelial tumor, polyp, granulomatous tissue, or bleeding source.
Biopsy is performed using:
- Cold cup biopsy forceps (most common; provides histologic architecture)
- Brush cytology (adjunct, not a separate billable service)
- Flat biopsy forceps for sessile or CIS lesions
Fulguration may follow biopsy or be performed alone:
- Electrocoagulation via a bugbee electrode or fulguration probe
- Laser fulguration (Holmium:YAG or Thulium fiber laser) — the laser delivery is bundled into 52354; laser lithotripsy of a stone would change the code to 52353
A ureteral stent (52332) may be placed at conclusion — separately reportable in some scenarios (payer-dependent; see Coding Nuances).
Specimen is sent to pathology — the pathology code (88305 or appropriate level) is billed separately by the pathologist and does not affect the surgical CPT code.

💰 Reimbursement & RVU Data

Component	Value (Approximate - Verify Current Year CMS MPFS)¹
Work RVU (wRVU)	8.10
Non-Facility Total RVU	~14.80
Facility Total RVU	~10.98
Global Period	000 (Zero-day global)
Assistant Surgeon Payable	❌ No (Indicator: 0 - Medicare; verify commercial payers)
Bilateral Surgery Indicator	3 - Cannot be bilateral (endoscopic; naturally unilateral per scope pass)
Co-Surgeon	❌ Not applicable
Team Surgery	❌ Not applicable

⚠️ wRVU Note: Values are updated annually with CMS Physician Fee Schedule (MPFS) rulemaking. Always verify against the current year’s CMS Physician Fee Schedule Look-Up Tool. The values above reflect recent published schedules.¹

📌 Comparison within the ureteroscopy family: 52354 carries a higher wRVU than 52352 (stone removal/manipulation) because biopsy and fulguration of upper tract lesions is considered a more technically demanding and oncologically significant procedure. It carries a lower wRVU than 52355 (resection of ureteral or pelvic tumor), which involves formal tumor resection rather than biopsy/fulguration only.

✅ Includes (Bundled - Do Not Bill Separately)

The following services are inherently included within 52354 and are not separately reportable:

Ureteral catheterization - explicitly stated in the code descriptor
Cystoscopy / cystourethroscopy (52000) - endoscopic access and bladder inspection required to reach the ureter
Diagnostic ureteroscopy component (52351) - the diagnostic visualization of the ureter/renal pelvis is integral when a therapeutic biopsy or fulguration is performed in the same session
Brush cytology of the ureter or renal pelvis - considered part of the endoscopic evaluation; not separately billable when performed in conjunction with 52354
Fluoroscopic guidance - intraoperative fluoroscopy used during standard ureteroscopy navigation is bundled under most payer policies
Laser energy delivery for fulguration - if a Holmium or Thulium laser is used to ablate a lesion (not a stone), the laser use is included in 52354
Irrigation and ureteral dilation necessary to pass the scope

🚫 Excludes / Cannot Bill Together (NCCI Edits & Bundling)

The following codes are subject to NCCI bundling edits with 52354 and generally cannot be billed on the same date for the same ureter without a valid modifier exception:²

Bundled Code	Description	Modifier Allowed?
52000	Cystourethroscopy (diagnostic)	❌ No
52005	Cystoscopy with ureteral catheterization	❌ No
52007	Cystoscopy with brush biopsy of ureter/renal pelvis	❌ No
52351	Diagnostic ureteroscopy (no therapeutic intervention)	❌ No
52204	Cystoscopy with biopsy (bladder biopsy - lower tract)	✅ Yes, with -59/-XS if truly separate lesion site
52214	Cystoscopy with fulguration (bladder lesion - lower tract)	✅ Yes, with -59/-XS if separate site
76000	Fluoroscopy, up to 1 hour	❌ Typically bundled
74420	Retrograde ureterography	Payer-specific; bundled by many MACs

Bladder vs. Upper Tract Lesions: If the surgeon biopsies or fulgurates a bladder lesion (52204 or 52214) AND a separate upper tract lesion (52354) in the same session, both codes may be reported with appropriate modifiers (-59 or -XS) because they involve different anatomic sites (lower vs. upper urinary tract). Operative documentation must clearly distinguish each lesion site and the separate interventions performed.

Stent Placement (52332): If a ureteral stent is placed at the conclusion of 52354, some payers allow separate billing of 52332 with modifier -59 or -XS. This is highly payer-dependent — many Medicare MACs bundle stent placement when performed in the same operative session as ureteroscopy. Always verify with the specific MAC or payer LCD/NCCI policy.

52354 + 52353 Conflict: If both fulguration of a lesion AND laser lithotripsy of a stone are performed in the same ureter during the same session, report both 52353 and 52354 with modifier -51 applied to the lesser-valued code. NCCI does allow billing both when distinct, separately documented therapeutic interventions are performed. Modifier -59 or -XS may be required depending on payer.

🌳 Code Tree - Ureteroscopy / Pyeloscopy Family

Cystourethroscopy with Ureteroscopy and/or Pyeloscopy
│
├── 52351 - Diagnostic only (no therapeutic intervention)
│               (ureteral catheterization included)
│
├── 52352 - With removal or manipulation of calculus
│               (ureteral catheterization included)
│
├── 52353 - With lithotripsy (laser, ultrasonic, electrohydraulic)
│               (ureteral catheterization included)
│
├── 52354 ◄ THIS CODE - With biopsy and/or fulguration of lesion
│               (ureteral catheterization included)
│
├── 52355 - With resection of ureteral or pelvic tumor
│               (more extensive than biopsy/fulguration; formal tumor resection)
│
└── 52356 - With lithotripsy INCLUDING insertion of indwelling ureteral stent
                (ureteral catheterization included)

Clinical Decision Point: 52354 vs. 52355

Upper Tract Lesion Identified on Ureteroscopy
│
├── Small, low-grade papillary tumor; biopsy + laser ablation/fulguration
│   └── Report: 52354
│
├── Larger urothelial lesion; endoscopic resection performed
│   (analogous to TURBT but in upper tract; loop resection or en bloc)
│   └── Report: 52355
│
└── Suspected stone + incidental lesion biopsied in same session
    └── Report: 52352 or 52353 (stone) + 52354 (biopsy) with -51/-59
        (payer-dependent; verify NCCI)

🏥 ICD-10-CM Diagnosis Codes Commonly Paired with 52354

Primary Malignant Diagnoses - Upper Urinary Tract

ICD-10-CM Code	Description	HCC v24	HCC v28
C65.1	Malignant neoplasm of right renal pelvis	HCC 11	HCC 17
C65.2	Malignant neoplasm of left renal pelvis	HCC 11	HCC 17
C65.9	Malignant neoplasm of unspecified renal pelvis	HCC 11	HCC 17
C66.1	Malignant neoplasm of right ureter	HCC 11	HCC 17
C66.2	Malignant neoplasm of left ureter	HCC 11	HCC 17
C66.9	Malignant neoplasm of unspecified ureter	HCC 11	HCC 17
C67.9	Malignant neoplasm of bladder, unspecified	HCC 11	HCC 17

⚠️ HCC Note: All primary malignant neoplasm codes above map to HCC 11 (Colorectal, Bladder, and Other Cancers) under CMS-HCC v24 and approximately HCC 17 under the restructured v28 model. These carry significant risk-adjustment weight and must be captured when documented, clinically evaluated, and clinically relevant. For inpatient encounters, query the physician if the diagnosis is referenced but not explicitly stated as confirmed — under inpatient guidelines, uncertain diagnoses may be coded if documented as such at discharge.

Metastatic & Advanced Disease

ICD-10-CM Code	Description	HCC v24	HCC v28
C79.01	Secondary malignant neoplasm of right kidney and renal pelvis	HCC 8	HCC 8
C79.02	Secondary malignant neoplasm of left kidney and renal pelvis	HCC 8	HCC 8
C79.19	Secondary malignant neoplasm of other urinary organs	HCC 8	HCC 8
C77.5	Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes	HCC 8	HCC 8

HCC 8 (Metastatic Cancer and Acute Leukemia) carries a substantially higher risk coefficient than HCC 11 — capturing metastatic disease accurately has major implications for risk adjustment and reimbursement accuracy.

Neoplasms of Uncertain Behavior

ICD-10-CM Code	Description	HCC v24	HCC v28
D41.11	Neoplasm of uncertain behavior, right renal pelvis	❌ No	—
D41.12	Neoplasm of uncertain behavior, left renal pelvis	❌ No	—
D41.19	Neoplasm of uncertain behavior, unspecified renal pelvis	❌ No	—
D41.21	Neoplasm of uncertain behavior, right ureter	❌ No	—
D41.22	Neoplasm of uncertain behavior, left ureter	❌ No	—
D41.29	Neoplasm of uncertain behavior, unspecified ureter	❌ No	—
D41.4	Neoplasm of uncertain behavior of bladder	❌ No	—

Coding Guidance - Uncertain Behavior vs. Awaiting Biopsy Results: The D41.xx codes are used when the physician has reviewed pathology and the tissue cannot be definitively classified as benign or malignant. They are not synonymous with “waiting for biopsy results.” If the operative report documents the procedure as exploratory or diagnostic-pending results, code the clinical signs/symptoms (e.g., hematuria) as the principal diagnosis for outpatient encounters. For inpatient, the uncertain diagnosis at the time of discharge may be coded per inpatient coding guidelines.³

Benign Lesion Diagnoses

ICD-10-CM Code	Description	HCC v24	HCC v28
D30.11	Benign neoplasm of right renal pelvis	❌ No	—
D30.12	Benign neoplasm of left renal pelvis	❌ No	—
D30.21	Benign neoplasm of right ureter	❌ No	—
D30.22	Benign neoplasm of left ureter	❌ No	—
N28.89	Other specified disorders of kidney and ureter (e.g., ureteral polyp, fibroepithelial polyp)	❌ No	—
Q62.39	Other obstructive defects of renal pelvis and ureter	❌ No	—

Symptomatic / Hematuria-Based Diagnoses

ICD-10-CM Code	Description	HCC v24	HCC v28
R31.0	Gross hematuria	❌ No	—
R31.1	Benign essential microscopic hematuria	❌ No	—
R31.21	Asymptomatic microscopic hematuria	❌ No	—
R31.29	Other microscopic hematuria	❌ No	—
R31.9	Hematuria, unspecified	❌ No	—

Outpatient Coding Guidance: Per UHDDS and AHA Coding Clinic guidance, if the procedure is performed to evaluate hematuria and a lesion is found and biopsied, the lesion/neoplasm (not the hematuria) should be coded as the first-listed diagnosis for outpatient encounters — assuming the lesion is the established reason for the procedure. Hematuria is a symptom of the underlying lesion; do not code both when the underlying condition is confirmed.³

High-Value Comorbidity / Complication Diagnoses (HCC-Relevant)

ICD-10-CM Code	Description	HCC v24	HCC v28
N18.3-	Chronic kidney disease, stage 3 (3a/3b)	HCC 137	HCC 329
N18.4	Chronic kidney disease, stage 4	HCC 137	HCC 329
N18.5	Chronic kidney disease, stage 5	HCC 136	HCC 328
N18.6	End stage renal disease	HCC 136	HCC 328
A41.9	Sepsis, unspecified organism	HCC 2	HCC 2
E11.65	Type 2 diabetes mellitus with hyperglycemia	HCC 19	HCC 37
Z85.51	Personal history of malignant neoplasm of bladder	❌ No	—
Z85.528	Personal history of malignant neoplasm of other urinary organ	❌ No	—
Z79.899	Other long term (current) drug therapy (e.g., BCG, checkpoint inhibitors)	❌ No	—

UTUC & CKD Intersection: Patients with upper tract urothelial carcinoma frequently have concomitant CKD — especially those who are candidates for kidney-sparing surgery rather than nephroureterectomy due to a solitary kidney or bilateral disease. CKD stage must be coded when documented and managed at the encounter, as it carries HCC weight and impacts downstream risk scores.

Personal & Family History Codes (Z-Codes - Not HCC but Clinically Relevant)

ICD-10-CM Code	Description
Z85.51	Personal history of malignant neoplasm of bladder
Z85.528	Personal history of malignant neoplasm of other urinary organs
Z80.9	Family history of malignant neoplasm, unspecified
Z12.79	Encounter for screening for other malignant neoplasms of urinary organs
Z08	Encounter for follow-up examination after completed treatment for malignant neoplasm

🏨 MS-DRG Assignment

Inpatient Coding Note: CPT codes apply to physician/professional fee billing and outpatient facility billing. For inpatient facility billing, ICD-10-PCS procedure codes — not CPT codes — drive MS-DRG assignment. MS-DRGs are determined by principal diagnosis + ICD-10-PCS procedure codes + presence of CC/MCC.

Relevant MS-DRGs (Primarily MDC 11 - Diseases & Disorders of the Kidney & Urinary Tract)

MS-DRG	Description	Approx. Relative Weight⁴
673	Other Kidney & Urinary Tract Procedures w/ MCC	~3.70
674	Other Kidney & Urinary Tract Procedures w/ CC	~1.90
675	Other Kidney & Urinary Tract Procedures w/o CC/MCC	~1.30

DRG 673-675 is the most common DRG grouping for ureteroscopy with biopsy/fulguration when the principal diagnosis is a ureteral or renal pelvic neoplasm, uncertain behavior lesion, or hematuria, AND a qualifying ICD-10-PCS OR procedure is performed (excision or destruction of upper urinary tract via endoscopic approach).

Oncology-Driven DRGs (MDC 11 - Urinary Neoplasm)

MS-DRG	Description	Approx. Relative Weight⁴
686	Kidney & Urinary Tract Neoplasms w/ MCC	~2.10
687	Kidney & Urinary Tract Neoplasms w/ CC	~1.20
688	Kidney & Urinary Tract Neoplasms w/o CC/MCC	~0.80

DRGs 686-688 may apply when the procedure performed does NOT qualify as an OR procedure under the grouper (e.g., if only a diagnostic ureteroscopy was documented without a clear therapeutic biopsy or fulguration), and the principal diagnosis is a neoplasm. Ensure ICD-10-PCS coding is complete and accurately reflects the root operation (Excision or Destruction) to drive DRG 673-675 rather than the lower-weighted 686-688.

If the patient is admitted with sepsis as the principal diagnosis secondary to an infected/obstructed tumor, the case shifts to MDC 18 (Infectious & Parasitic Diseases). Principal diagnosis sequencing in complex oncologic inpatients requires careful clinical documentation review and, when indicated, physician queries.³

ICD-10-PCS Equivalents (Inpatient Facility Billing)

Biopsy (Root Operation: Excision - “B”) Qualifier: X = Diagnostic

ICD-10-PCS Code	Description
0TB37ZX	Excision of right kidney pelvis, via natural or artificial opening endoscopic, diagnostic
0TB47ZX	Excision of left kidney pelvis, via natural or artificial opening endoscopic, diagnostic
0TB67ZX	Excision of right ureter, via natural or artificial opening endoscopic, diagnostic
0TB77ZX	Excision of left ureter, via natural or artificial opening endoscopic, diagnostic

Fulguration/Ablation (Root Operation: Destruction - “5”)

ICD-10-PCS Code	Description
0T537ZZ	Destruction of right kidney pelvis, via natural or artificial opening endoscopic
0T547ZZ	Destruction of left kidney pelvis, via natural or artificial opening endoscopic
0T557ZZ	Destruction of right ureter, via natural or artificial opening endoscopic
0T567ZZ	Destruction of left ureter, via natural or artificial opening endoscopic

Root Operation Guidance: If both biopsy and fulguration are performed on the same lesion (tissue sampled, then ablated), both root operations (Excision and Destruction) may be coded if the documentation clearly supports each distinct action. Code the most definitive root operation first. If uncertain whether Excision or Destruction best captures the procedure, a physician query or review of AHA Coding Clinic guidance is warranted.³

Qualifier X (Diagnostic): The diagnostic qualifier (X) is appended to Excision codes when the biopsy is performed to obtain a specimen for pathologic examination. This is a critical qualifier and must be present on inpatient biopsy codes to ensure accurate DRG assignment and proper clinical representation.

🏷️ Modifiers Applicable to 52354

Modifier	Description	Use Case
-LT	Left side	Lesion in left ureter or left renal pelvis
-RT	Right side	Lesion in right ureter or right renal pelvis
-22	Increased procedural services	Unusually extensive procedure (e.g., multiple biopsies, difficult anatomy, extensive fulguration); requires documentation and often written attestation of increased physician work and time
-51	Multiple procedures	When 52354 is performed alongside another distinct endoscopic procedure (e.g., 52353 for stone, 52204 for bladder biopsy); 50% reduction typically applied to lesser procedure
-52	Reduced services	Procedure attempted but only partially completed (e.g., lesion visualized but only brush cytology obtained; biopsy forceps could not be deployed); document why full procedure not completed
-53	Discontinued procedure	Procedure initiated and terminated due to patient safety concern before biopsy/fulguration performed
-58	Staged or related procedure	If fulguration is planned as a staged second procedure following initial biopsy/awaiting pathology (within global period — note: 52354 has 000-day global, so -58 is rarely needed but may apply if a related staged procedure within the same surgical episode is planned)
-59	Distinct procedural service	Used to unbundle a separately reportable service from 52354 (e.g., bladder biopsy 52204 for a separate bladder lesion, or stent placement 52332); payer-dependent
-XS	Separate structure (HCPCS X-modifier)	CMS preferred alternative to -59 for distinct anatomic site procedures
-76	Repeat procedure by same physician	If 52354 must be repeated on the same day by the same provider (unusual; document necessity)

Laterality Modifiers: 52354 does not have a bilateral indicator that allows billing both ureters as “bilateral.” If lesions in both ureters are biopsied/fulgurated in the same session, report 52354 twice — once with -RT and once with -LT — and append -51 to the lower-valued code. Some payers may bundle; verify before submitting both.

📖 Coding Examples

Example 1 - Ureteroscopic Biopsy of Right Renal Pelvis Lesion, Outpatient

A 68-year-old male with a history of bladder urothelial carcinoma presents with right flank pain and gross hematuria. CT urogram reveals a 1.4 cm filling defect in the right renal pelvis. The urologist performs cystourethroscopy and advances a flexible ureteroscope into the right ureter to the renal pelvis. A papillary lesion is visualized and multiple cold-cup biopsies are obtained using biopsy forceps. No fulguration is performed. Specimens sent to pathology — results pending.

CPT: 52354--RT ICD-10-CM (Outpatient - First Listed): R31.0 (gross hematuria) — if the lesion is not yet confirmed histologically at time of coding, symptom-driven principal diagnosis is appropriate in outpatient setting. If lesion has been confirmed or the diagnosis is established in the chart, use C65.1 or D41.11 per documentation. Additional Diagnoses: Z85.51 (personal history of bladder malignancy)

✅ Coding Tip: For outpatient encounters, do not code a malignancy until pathology confirms it. Code the presenting sign/symptom (hematuria) as the first-listed diagnosis if the procedure is performed to evaluate the finding. Code the confirmed diagnosis once pathology returns, typically on the follow-up encounter.

Example 2 - Biopsy AND Fulguration of Left Ureteral Lesion

A 72-year-old female with known left ureteral low-grade papillary urothelial carcinoma presents for surveillance ureteroscopy. A 5mm papillary lesion is identified at the mid-left ureter. The surgeon takes multiple biopsy specimens and then performs laser fulguration of the lesion using a Holmium:YAG laser. A ureteral stent is placed at the end of the procedure.

CPT: 52354--LT (Stent placement: payer-dependent — consider 52332--LT--59 if payer allows separate billing) ICD-10-CM: C66.2 (malignant neoplasm of left ureter)

✅ Both biopsy AND fulguration are captured by a single unit of 52354 — do not report the code twice. The single code encompasses both services when performed in the same session, same ureter.

Example 3 - Ureteroscopic Biopsy + Bladder Tumor Fulguration Same Session

A 65-year-old male with a history of bladder cancer on surveillance cystoscopy is found to have a small recurrent papillary bladder tumor at the right lateral wall AND a suspicious lesion at the right ureterovesical junction extending into the distal right ureter. The urologist fulgurates the bladder tumor and advances the ureteroscope into the right ureter and biopsies the ureteral lesion.

CPT:

52214--RT (cystoscopy with fulguration of bladder lesion)
52354--RT--59 (ureteroscopy with biopsy of ureteral lesion — distinct from bladder procedure by site; -59 or -XS establishes separate anatomic location)

ICD-10-CM:

C67.9 (malignant neoplasm of bladder — established)
D41.21 (neoplasm of uncertain behavior, right ureter — pending pathology)

⚠️ NCCI Alert: 52214 and 52354 are subject to bundling edits. The -59/-XS modifier on 52354 is required to establish that the ureteral biopsy was performed at a distinct anatomic site (upper urinary tract) separate from the bladder fulguration. Operative note must clearly document both sites and both procedures individually.

Example 4 - Inpatient Encounter: UTUC with Obstructive Uropathy

A 77-year-old female is admitted with left flank pain, hydronephrosis, and weight loss. Imaging reveals a 2.2 cm mass in the left ureter with proximal hydronephrosis and ureteral obstruction. The urologist performs left ureteroscopy with biopsy of the obstructing mass and placement of a ureteral stent for decompression. Pathology returns urothelial carcinoma, high grade. CKD stage 3b is documented and managed during the admission.

Principal Diagnosis: C66.2 (malignant neoplasm of left ureter) Secondary Diagnoses:

N13.5 (crossing vessel and stricture/obstruction with hydronephrosis — or N13.2 if calculus-related; select appropriate obstruction code per documentation)
N18.32 (CKD stage 3b) — HCC 137
R31.0 (hematuria — symptom of underlying malignancy; may be omitted if not separately managed)

ICD-10-PCS Procedures:

0TB77ZX (Excision of left ureter, via natural or artificial opening endoscopic, diagnostic — biopsy)
0T178DZ (Bypass of left ureter — if stent coded as bypass) or appropriate drainage/bypass code per Coding Clinic

MS-DRG: Likely DRG 673 (Other Kidney & Urinary Tract Procedures w/ MCC) if N18.32 or hydronephrosis qualifies as MCC; otherwise DRG 674 with CC. Verify with your facility’s grouper. CKD stage 3b typically qualifies as a CC, supporting DRG 674 at minimum.

Example 5 - Diagnostic Attempt Converted to Brush Cytology Only (Reduced Service)

A 60-year-old male undergoes right ureteroscopy for evaluation of a suspicious filling defect seen on CT urogram. Upon scope insertion, severe ureteral tortuosity prevents advancement of the ureteroscope beyond the mid-ureter. Brush cytology is obtained at the accessible level. Biopsy forceps are not deployed. A ureteral stent is placed to allow passive dilation.

CPT: 52351--RT (diagnostic ureteroscopy — therapeutic biopsy not performed; only diagnostic scope and brush cytology) Alternatively: 52354--RT--52 (reduced services — biopsy attempted but not completed; document clearly) Second code: 52332--RT--59 (stent placement, if payer allows) ICD-10-CM: R31.0 (gross hematuria) or N28.89 (ureteral lesion, unspecified), N13.5 (stricture)

🔑 Coding Decision: The distinction between 52351 and 52354--52 depends on whether biopsy was attempted or simply not considered — if the physician’s intent was to biopsy and the scope could not reach the lesion, -52 on 52354 may be more accurate. If the encounter was always diagnostic only with brush cytology, 52351 is cleaner. Documentation must support the code choice.

Example 6 - Surveillance Ureteroscopy, No Lesion Found (Negative Exam)

A 70-year-old male with history of left renal pelvis urothelial carcinoma, status post laser fulguration 6 months ago, presents for surveillance ureteroscopy. Flexible ureteroscope is advanced into the left renal pelvis; no lesion is identified. Brush cytology obtained. Procedure is documented as “negative surveillance ureteroscopy.”

CPT: 52351--LT (diagnostic ureteroscopy — no biopsy, no fulguration, no therapeutic intervention performed) ICD-10-CM:

Z08 (encounter for follow-up examination after completed treatment for malignant neoplasm)
Z85.528 (personal history of malignant neoplasm of other urinary organ — renal pelvis)

✅ When no biopsy or fulguration is performed — even if it was intended — only 52351 is reportable. The absence of a lesion means no therapeutic intervention was provided. Do not report 52354 for a negative exam.

Code	Description
52351	Diagnostic ureteroscopy/pyeloscopy (no therapeutic intervention)
52352	Ureteroscopy with removal or manipulation of calculus
52353	Ureteroscopy with lithotripsy
52355	Ureteroscopy with resection of ureteral or pelvic tumor
52356	Ureteroscopy with lithotripsy + ureteral stent placement
52332	Cystoscopy with insertion of indwelling ureteral stent
52007	Cystoscopy with brush biopsy of ureter/renal pelvis
52204	Cystoscopy with biopsy of bladder
52214	Cystoscopy with fulguration of bladder lesion
52000	Cystourethroscopy (diagnostic, lower tract only)
88305	Surgical pathology, gross and microscopic exam - Level IV (typical level for ureteral biopsy)
88307	Surgical pathology - Level V (may apply for complex or resection specimens)
74420	Retrograde ureterography
50390	Aspiration/injection of renal cyst
50606	Endoluminal biopsy of ureter and/or renal pelvis (non-endoscopic, radiologic)

📝 Clinical & Documentation Tips for Coders

Always specify laterality in both the operative report and diagnosis coding. C66.1 (right ureter) vs. C66.2 (left ureter) — these are distinct codes and must match what is documented in the operative report.
Confirm whether biopsy, fulguration, or both were performed — all three scenarios are captured by 52354 in a single session, but the operative report must specifically state which intervention occurred. If only brush cytology is obtained, this does not meet the threshold for 52354.
Pathology codes are separately billable — 88305 or the appropriate level of surgical pathology is billed by the pathologist or laboratory and does not conflict with 52354 for the surgeon.
Brush cytology alone (52007) does not support 52354 — tissue biopsy or fulguration must occur.
For inpatient coding, ensure the diagnostic qualifier (X) is present on all Excision (biopsy) ICD-10-PCS codes — omitting it will misrepresent the procedure as therapeutic resection rather than diagnostic biopsy and may affect DRG accuracy.
Personal history codes (Z85.51, Z85.528) are important for surveillance encounters and should be captured consistently — they may not drive reimbursement but are critical for quality reporting and risk stratification.
CDI Opportunities on Inpatient UTUC Cases: Query for CKD stage, anemia related to malignancy, nutritional status (malnutrition, weight loss with malignancy), hydronephrosis/obstructive uropathy, and any infectious complications — all of which may qualify as CC/MCC and affect DRG weight.
UTUC and Lynch Syndrome (Z15.09 or Z84.81): In younger patients or those with family history of Lynch syndrome-associated cancers, documentation of hereditary risk may be relevant for Z-code capture and MDH quality metrics.

📚 References

CMS Physician Fee Schedule - MPFS Look-Up Tool. cms.gov/medicare/physician-fee-schedule ↩ ↩²
CMS National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services. cms.gov/medicare/coding-billing/national-correct-coding-initiative-edits ↩
AHA Coding Clinic for ICD-10-CM/PCS. American Hospital Association. ahacodingclinic.org ↩ ↩² ↩³ ↩⁴
CMS MS-DRG Definitions Manual & IPPS Final Rule. cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps ↩ ↩²

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