Question: I’m unsure how to code for cannulation of colovesical fistula. The doctor also did a cystoscopy with bilateral retrogrades and bladder biopsies. How should I report this procedure?
Answer: There is no specific CPT code for cannulation of the tract. Therefore, you should report the unlisted code 53899 (Unlisted procedure, urinary system), and explain fully what was performed. If your urologist cannulated the fistulous tract and injected contrast you could report 20501 (Injection of sinus tract; diagnostic [sonogram]). In this case the sinus tract is the fistula or tract between the bladder and colon.
You should also bill 52204 (Cystourethroscopy, with biopsy[s]) and 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) with modifier 59 (Distinct procedural service) if the cystoscopy and retrograde represents a diagnostic procedure.
If your urologist also interpreted the retrograde pyelogram and separately documented the reading in the medical records, you may also report 74420-26 (Urography, retrograde, with or without KUB; professional component).
