CPT code 52204: Cystourethroscopy with biopsy (s)

What is cystourethroscopy with biopsy?

CPT code 52204 refers to cystourethroscopy with biopsy, a diagnostic and sometimes therapeutic bladder transurethral surgical procedure. It involves the use of a cystoscope inserted through the urethra to examine the bladder wall, prostatic urethra, and ureteric openings, allowing for targeted bladder biopsy of suspected lesions or abnormalities, such as bladder tumors or early-stage bladder cancer.

This surgical procedure plays a vital role in diagnostic cystoscopy, surveillance settings, and BLC treatment, particularly for patients undergoing evaluation for bladder neck abnormalities, clot evacuation, or urethral dilation.

Widely recognized by the American Medical Association, CPT code 52204 is crucial for accurate coding and proper reimbursement, particularly in hospital outpatient settings and ambulatory surgical centers. With recently approved Medicare reimbursement changes and complexity adjustments it helps maximize reimbursements while improving patient access, detection, and procedure performance.

This medical coding is also important in capturing laser surgery, indwelling ureteral stent work, and procedures billed alongside urethral catheterization.

Documentation requirements

52204 CPT code requires an operative note that supports accurate coding and appropriate reimbursement by including the following details:

• Clinical indication (e.g., hematuria, bladder cancer, or tumor surveillance)
• Detailed description of the cystoscopic approach and anatomical structures evaluated (e.g., bladder wall, urethra, ureteric openings)
• Location, size, and appearance of any lesions biopsied, such as bladder tumors or suspicious areas
• Biopsy technique used (cold cup, loop, laser) and specimen handling process
• Type of anesthesia used and patient’s response or tolerance
• Any intraoperative complications and post-procedure follow-up plan
• Pathology submission details, including specimen labeling and documentation of transmission

This level of detailed documentation ensures accurate coding of healthcare systems, meets Medicaid services and AMA guidelines, and helps maximize reimbursements under recently approved Medicare reimbursement adjustments.

Billing guidelines

Proper billing of CPT Code 52204 requires adherence to specific coding rules and documentation standards to ensure accurate reimbursement. Check the following:

• Report once per session, regardless of how many biopsies or anatomical sites are sampled.
• Do not report CPT 52204 with CPT 52000 (diagnostic cystoscopy) on the same date of service—52204 includes the diagnostic component.
• Modifier -50 is not applicable since cystourethroscopy with biopsy is inherently bilateral by nature.
• Use modifier -26 (professional component) or -TC (technical component) when services are split in a hospital outpatient or ambulatory surgical center setting.

Ensure operative documentation supports clinical complexity, differentiating it from a standard diagnostic cystoscopy.

Other relevant CPT codes

• 52214 – Cystoscopy with fulguration
• 52000 – Cystoscopy without intervention
• 52224 – Cystoscopy with transurethral resection