Urology Coding Alert

Tip: Start with checking the patient’s age.

A meatotomy is a procedure during which the surgeon makes an incision to enlarge the urethral meatus (the opening of the urethra) to improve the patient’s urination capability. If you haven’t coded one of these in a while, read on for some refreshers on points to keep in mind.

Focus on the Patient’s Age

CPT^® 2018 includes only two codes for meatotomy:

• 53020 – Meatotomy, cutting of meatus (separate procedure); except infant)
• 53025 – … infant.

As you can see from the simple descriptors, the only difference between the codes is the patient’s age: infant or not an infant. In coding vernacular, “infant” means that the patient is one year of age or younger. A meatal stenosis or stricture may be congenital (Q64.33, Congenital stricture of urinary meatus), acquired, ie., post-infective (N35.111, Postinfective urethral stricture, not elsewhere classified, male, meatal), post-procedural (N99.110, Postprocedural urethral stricture, male, meatal), or post-traumatic (N35.010, Post-traumatic urethral stricture, male, meatal, and other urethral stricture, male, meatal).

Plus: Another diagnosis, N35.811 (Other urethral stricture, male, meatal) is new for 2019.

What happens: Once the patient is prepped and anesthetized, the surgeon incises the ventral lip of the urethral meatus. Depending on the complexity, the provider might extend the incision to increase the opening of the urethral meatus. The surgeon might also dilate the meatus to widen the opening even further. Once the procedure is complete, the physician approximates the edges of the urethral meatus to ensure that the meatus will stay open.

Follow These Real-World Tips

As with any procedure, successfully coding for meatotomy often depends on how well you know the associated details. For example:

• Because meatotomy is coded based on the patient’s age, ensure that the urologist remembers to make note of the patient’s age in the operative report.
• Note that code 53020 is excluded from modifier 63 (Procedure performed on infants less than 4 Kg). Do not append modifier 63 to the claim when reporting 53020.
• A meatotomy code is identified as a separate procedure. That designation indicates that when the surgeon performs a meatotomy during the same operative session as a more complex procedure, you do not separately report the meatotomy.
• If the urologist performs a meatotomy with other procedures or services and documentation supports its use as a separate distinct procedure, be sure to review the NCCI edits to see if the procedures are bundled before you report both. If the documentation provides support, and the modifier is allowed, append modifier 59 (Distinct procedural service) or one of the X[EPSU} modifiers to the meatotomy code.
• When 53020 or 53025 are performed with another separately identifiable procedure, the higher-dollar value code is listed as the primary procedure and subsequent procedures are reported with modifier 51 (Multiple procedures) appended.

Familiarize Yourself With the Edits

As noted above, it’s not uncommon for the urologist to perform meatotomy during the same session as another procedure. Be mindful of the other procedure and whether you can report both on the claim.

Example: The urologist performed a takedown of penile adhesions plus urethral dilation and meatotomy with meatoplasty for an adult. How should I code this?

Example answer:  Report code 53450 (Urethromeatoplasty, with mucosal advancement) for both the meatotomy and the meatoplasty. Don’t report the meatotomy code 53020, since it is bundled into 53450 and under no circumstances can it be unbundled, according to National Correct Coding Initiative guidelines.

For the lysis of penile adhesions, report code 54162 (Lysis or excision of penile post-circumcision adhesions), and report 53600 (Dilation of urethral stricture by passage of sound or urethral dilator, male; initial) for the urethral dilation.

Explanation: “Meatotomies and urethrotomies are no longer paid when billed with certain cystoscopic procedures such as 52601 (TURP) and 52648 and 52649 (laser prostatectomies), which are often performed with the above to avoid urethral injury during these endoscopic procedures” says Michael A. Ferragamo, MD, FACS,  clinical assistant professor of urology at the State University of New York at Stony Brook.

Coding edits assign a modifier indicator of “0” to these code pairs, which means you can never separately report the services. In other words, you can never bypass these edits with any modifier, including modifier 59.