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Urology Coding Alert

You Be the Coder:

Choose a V Code to Diagnose Stomal Stenosis

Published on Thu Oct 09, 2003

Question: What diagnosis and procedure codes should I use to report dilation of ileal conduit stoma for stenosis?
    
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Answer: The correct procedure code depends on what other services were rendered during the patient encounter.
If the patient came in for an office visit, and the physician decided to perform the dilation as a result of the E/M service, the dilation is considered included in the E/M service and is not separately reportable. 
 
If the patient came in solely for the dilation of the stomal stenosis, you should report the unlisted- procedure code 44799 (Unlisted procedure, intestine).
 
Regardless of the procedure code, you should report 997.5 (Urinary complications) as the primary diagnosis code; you may report V55.8 (Attention to other specified artificial opening) as the secondary diagnosis.
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