Urology Coding Alert

Question: A patient had end-to-end urethroplasty with a buccal mucosal urethroplasty including graft harvest because of an anterior urethral stricture. He returned two weeks later for what the urologist documented as a “suture ligation of bleeding vessel and drainage of a hematoma at the buccal graft site.” What CPT^® code should I report? And do I include modifier 78?

West Virginia Subscriber

Answer: Report 10140 (Incision and drainage of hematoma, seroma or fluid collection). This will include the ligation of bleeding vessels.

Associate the procedure with ICD-10-CM diagnosis L76.32 (Postprocedural hematoma of skin and subcutaneous tissue following other procedure).

The original surgery should have been filed with 53410 (Urethroplasty, 1-stage reconstruction of male anterior urethra) and 15240 (Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less) for the harvesting of the buccal graft. Because the procedure usually is completed in a single session, include modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) for the treatment of a postoperative surgical complication on this second claim and have clear documentation of why the return to surgery was necessary.