Urology Coding Alert

A post-op scenario proves that success lies in the op report details Seeing a postsurgical complication such as "bladder neck contracture" in the op report can lead you to several different codes, so you have to dig deeper to uncover all the details you need for selecting the correct one. A coder in a Pennsylvania urology practice submitted an op report with just such a challenge. See how our experts approach this coding puzzle, and then apply these concepts to your most difficult cases.
Examine the Details Here are the details from the subscriber's op note: Patient: A male who had a radical retropubic prostatectomy four months ago for carcinoma of the prostate presents with a decrease in size and force of his urinary stream, frequency, and urgency of urination. Findings and diagnosis: Urethral stricture in the bulbous urethra and a "bladder neck contracture" at the vesicourethral anastomosis. Operative report: "Patient underwent a transurethral incision of the urethral stricture using a cold knife. Patient also underwent an incision of the bladder neck with the cold knife. Foley catheter placed for 24-48 hours of catheter drainage. " Procedures: The urologist states that he performed a visual incision of a urethral stricture, visual internal urethrostomy, and also a visual incision of the bladder neck contracture at the same encounter.
Break Down the Report Procedure coding: The proper CPT code for the bladder neck contracture incision(s) depends on the contracture's etiology, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook. In this case, because the contracture is secondary to a previous radical prostatectomy, you'll report 52276 (Cystourethroscopy with direct vision internal urethrotomy). Tip: You should report 52276 whether the urologist uses a cold knife, hot knife or laser to incise the contracture. This "bladder neck contracture" really represents a urethral stricture at the urethrovesical anastomotic site rather than a true bladder neck contracture, Ferragamo says. Remember, the urologist removed this patient's prostate and true bladder neck with the radical prostatectomy specimen. For the bulbous urethral stricture, you'll report 52276 again as your second code with modifier 59 (Distinct procedural service) appended. You need to add modifier 59 to explain to your carrier that reporting the same code twice is not an error, but that your physician performed these two identical procedures for different pathological processes and that both procedures warrant payment. This situation meets the requirement for using modifier 59 per Correct Coding Initiative (CCI) guide-lines because the urologist did the second service at a separate part of the urinary tract, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis. Diagnosis coding: [...]