Urology Coding Alert

Question: My urologist performed the following: revision of bladder augmentation, bladder neck closure (CPT 51800 ), lysis of adhesions, cystoscopy (52000), and revision of suprapubic cystostomy. How should I report all of this?


California Subscriber


Answer: First, you should report 51555 (cystectomy, partial; complicated [e.g., previous surgery]) for the revision of the enterocystoplasty, especially if it included removal of part of the implanted intestinal patch and or bladder wall.

Next, you'll use 51800 (Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck [anterior Y-plasty, vesical fundus resection], any procedure, with or without wedge resection of posterior vesical neck) for the closure of the bladder neck.

Important: For non-Medicare carriers, be sure to append modifier 51 (Multiple procedures) to 51800 to indicate that the urologist performed the closure along with other procedures. Medicare carriers will append the modifier for you.

Finally, report 51040 (Cystostomy, cystotomy with drainage) for the revision of the cystostomy. Append modifier 51 to this code, as well as modifier 52 (Reduced services). However, you should leave off modifier 52 if the urologist performed a new cystostomy at a new site.

Avoid: The National Correct Coding Initiative bundles cystoscopy code 52000 (Cystourethroscopy [separate procedure]) into the cystostomy, and you cannot unbundle them, so you should not separately report 52000. If the lysis of adhesions necessitates a significant amount of time and prolonged the full procedure significantly, add modifier 22 (Unusual procedural services) to indicate the extra work and time spent and also remember to request additional reimbursement.