Urology Coding Alert

Question: During the course of a laparoscopic assisted vaginal hysterectomy, an ob-gyn lacerated the bladder. He then consulted with my urologist, who went to the OR to repair the laceration, but because of anatomical reasons was unable to do so. Instead, he performed a cystoscopic examination and elected to treat the minor laceration with long-term Foley catheter bladder drainage. The patient is following up with my urologist. What should I report and what should the ob-gyn's coder report? Are there any regulations preventing me from reporting my urologist's services because they were for a surgical complication?


Arizona Subscriber


Answer: Medicare has a rule that the operating surgeon should not report repair of any injury caused during the surgery unless the repair significantly prolongs the surgery. This applies to the surgeon who created the problem, not another physician called to perform a repair.

In your case, the ob-gyn asked your urologist to evaluate the bladder laceration. Therefore, the ob-gyn should only bill for the laparoscopic assisted vaginal hysterectomy using 58550-58554 (Laparoscopy, surgical, with vaginal hysterectomy ...).

On the other hand, you can report the cystoscopy (52000, Cystourethroscopy [separate procedure]) for your urologist's services. This code also includes the insertion of the Foley catheter. Link the procedure code to a diagnosis of 998.2 (Accidental puncture or laceration during a procedure).