Urology Coding Alert

Question: My urologist noted that a patient “underwent a repair of a rectourethral fistula with omental flap that developed  postoperatively after a robotic radical prostatectomy.” How should I report this procedure?


South Dakota Subscriber

Answer: First you should report 45820 (Closure of rectourethral fistula) for the repair of the fistula. Second, you’ll report +49905 (Omental flap, intra-abdominal [list separately in addition to code for primary procedure]) for your physician’s use of an intra-abdominal omental flap.

Tip: Code 49905 is an “add on” code, so you do not need to append modifier 51 (Multiple procedures) to prevent a reduced fee. However, if the repair was performed during the 90-day global of the radical prostatectomy, add modifier 78 (Return to the operating room for a related procedure during the postoperative period) to both of the above codes to indicate the treatment of a surgical complication.

Diagnosis: The appropriate ICD-9 for the complication would be 998.6 (Other complications of procedures, not elsewhere classified; persistent postoperative fistula).