Urology Coding Alert

Question: What is the code for a post-prostatectomy bladder neck contracture that was treated by an incision? Does this require an unlisted-procedure code? New York Subscriber Answer: Although the unlisted-procedure code is a viable option, consider using a more specific code to represent the incisional bladder neck contracture. Bladder neck contracture is common in patients after the removal of the prostate, when scar tissue builds up where the prostate was located prior to surgery. Typically, the scar tissue is removed using a resectoscope, but some urologists may opt to incise the scar tissue as indicated in your question. If you use the unlisted-procedure code 53899 (Unlisted procedure, urinary system), be sure to have detailed documentation of the actual procedure performed and be prepared to submit it to the carrier. You also have the option of using the code for the standard resection of bladder neck contracture, 52640 (Transurethral resection; of postoperative bladder neck contracture), with modifier -52 (Reduced services). Modifier -52 will indicate to the carrier that the incisional method does not require the same amount of work as the resection method, so there should be a reduction in the fee.