Urology Medical Coding: Complete Guide with New Codes, Guidelines, and Tips

What Makes Urology Coding Unique

Urology coding must capture a wide range of services — from office visits and diagnostic testing to endoscopic procedures and complex prostate or reconstructive surgeries. Accurate coding ensures compliance, proper reimbursement, and fewer claim denials.

Urology coding relies on:

• ICD-10-CM codes for diagnosis

• CPT codes for procedures and services

• Appropriate modifiers when multiple procedures are performed or when services occur in different settings

Staying current with annual code updates is critical. CPT and ICD-10 code changes each year can affect documentation requirements and reimbursement.

Latest CPT Code Changes in Urology

Major 2026 Updates

The 2026 CPT code set introduced numerous updates that directly affect urology coding, particularly for prostate procedures and advanced surgical technologies.

Prostate Biopsy Code Overhaul

Previously, a single code (55700) was used for prostate biopsies. For 2026, that code was deleted and replaced with nine new CPT codes (55707–55715) that differentiate:

• Approach (transrectal vs transperineal)

• Guidance method (ultrasound vs MRI-ultrasound fusion vs in-bore imaging)

• Number of targeted lesions (add-on code +55715 for additional lesions)

This change improves specificity and reflects modern biopsy techniques, but it also increases documentation demands so that the correct technique and guidance method are supported in the record.

Aquablation Now a Category I Code

CPT 52597 is now the code for transurethral robotic-assisted waterjet resection of prostate tissue (Aquablation). This replaces its prior status as a Category III emerging technology code.

Legacy Code Deletions

• 52647 (laser coagulation of the prostate) deleted for 2026 — coders must identify alternative CPT codes based on the actual therapy used.

Laparoscopic & Minimally Invasive Procedures

Codes such as 51990 and 51992 describe laparoscopic urethral suspensions, increasingly used in incontinence surgeries.

Key Urology CPT Code Categories

Evaluation & Management (E/M) Codes

These are used for outpatient and inpatient visits:

• 99202–99205: New patient office/outpatient visits

• 99211–99215: Established patient office/outpatient visits

• 99221–99223, 99231–99233: Initial/subsequent hospital care

• 99281–99285: Emergency department

• 99354–99357: Prolonged E/M services

Documentation Tip: Use either the Medical Decision Making (MDM) or time-based documentation rules depending on the service and payer requirement.

Diagnostic & Endoscopic CPT Codes

Commonly used urology CPT codes include:

• 51701–51703: Bladder catheterization

• 51725–51728: Urodynamic testing

• 52000–52005: Cystoscopy and related services

• 52400: Cystourethroscopy with treatment (e.g., lasers for obstruction)

Selecting the correct code depends on whether the procedure is diagnostic only or therapeutic (i.e., includes treatment).

Surgical CPT Codes

A sample of surgical codes:

• 55045: Transurethral resection of prostate (TURP)

• 52601: Laparoscopic prostatectomy

• 52597: Aquablation of prostate

• Prostate biopsy codes 55707–55715: Approach- and guidance-specific coding

Always refer to the official CPT manual for full descriptors and bundling instructions.

ICD-10 Coding for Urology

Accurate diagnosis coding ensures services match procedural claims and support medical necessity.

Some common ICD-10 codes in urology include:

• N39.0: Urinary tract infection

• N20.0: Calculus of the kidney

• N39.3: Stress incontinence

• C61: Malignant neoplasm of prostate

• N18.1–N18.6: Chronic kidney disease stages

Updates in ICD-10 may add specificity for conditions such as immune complex kidney diseases or hereditary nephropathies, often relevant in complex urological cases.

Documentation Tip: Capture laterality, severity, and any underlying cause (e.g., genetic or immunologic factors) when supported by clinical findings.

Urology Coding Guidelines & Best Practices

Follow these general principles to reduce denials and increase clean claims:

Document Thoroughly

Clear documentation is the foundation of accurate coding. Include:

• Procedure details (technique, guidance used, laterality)

• Diagnostic rationale and clinical findings

• Tools or technologies (e.g., MRI fusion) used in procedures

Link Diagnosis to Service

Always link the most appropriate ICD-10 code to each CPT service. Payers often deny claims when the diagnosis does not justify the service rendered.

Understand Bundling & Add-Ons

Some CPT codes bundle certain services together. For example:

• Imaging guidance may be bundled into prostate biopsy CPT codes; do not report separate guidance CPT codes when bundled.

• Add-on codes (e.g., +55715) require a primary service code to be valid.

Medical Coding Bundling and Upcoding 

Modifier Use

Modifiers can help clarify unusual circumstances:

• Modifier 59 / X{EPSU}: Distinct procedural service

• Modifier 25: Significant, separately identifiable E/M on the same day as a procedure

• Modifier 22: Increased procedural service

Apply them only when supported by documentation.

CPT Modifiers 

Stay Current With Payer Rules

Medicare and private payers often interpret CPT and ICD-10 guidelines differently — review payer coding manuals regularly and watch Local Coverage Determinations (LCDs) such as urodynamics coverage under Medicare, which require specific clinical criteria.

Common Pitfalls and How to Avoid Them

Pitfall: Using outdated or deleted CPT codes
Solution: Review annual CPT updates; crosswalk deleted codes to current replacements.

Pitfall: Billing bundled imaging separately
Solution: For codes like the new prostate biopsy series, avoid separate imaging codes when guidance is included.

Pitfall: Inadequate documentation
Solution: Educate providers on the need for detailed notes that support procedures and diagnosis specificity.

Urology coding is complex but manageable with a structured approach:

• Stay updated with annual CPT and ICD-10 changes

• Emphasize accurate documentation

• Use appropriate modifiers

• Link diagnoses to services correctly

Following these practices will improve compliance, reduce denials, and maximize reimbursement for urology services.

Renal Physicians Association 

American Urological Association 

American Association of Clinical Urologists