Urology Coding Alert

Question: My urologist performed a urethrotomy prior to a TURP procedure because of a bladder neck contracture. Can we bill for the urethrotomy separately? UCA Subscriber Answer: You've hit on one of the coding scenarios that really require you to know the nuances of the CPT guidelines and descriptors. The definition of the standard TURP procedure, 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]), indicates that a urethrotomy is included in the fee for the TURP procedure. However, in the case of a bladder neck contracture or stricture, if there is documentation of it pre-existing the surgery, you should be reimbursed for the additional work required by the urethrotomy. Append modifier -22 (Unusual procedural services) to code 52601 and include a copy of the operative report with the claim to indicate that there was additional work involved because of the bladder neck contracture.