Urology Coding Alert

Question: We had a patient who was two days post op from a TURBNC (52500). The patient had to go back to the OR, and the urologist's documentation states:

"Then using the Olympus 26-French resectoscope sheath with the Schmidt obturator, visual urethroscopy was carried out. The distal urethra was open and clear. The verumontanum was intact. The prostatic fossa had blood clots and debris within it. The bladder neck had an adherent blood clot. The bladder was filled with blood clots.  After passage of the instrument a Toomey syringe was used to evacuate the blood clots. Then the Iglesias resectoscope was inserted. Bleeding was noted to be coming from the area of the bladder neck at around the 6 o'clock position and another area around the 11 o'clock position. Using the resectoscope, these areas were resected and their bases re-cauterized. The bladder was cleared and freed of all tissue debris and clot. There was no further bleeding noted."

How should I code for this procedure performed during the post op global period of the original period?

Idaho Subscriber

Answer: First, report 52500 (Transurethral resection of bladder neck [separate procedure]) for the transurethral resection of a bladder neck contracture (TURBNC). Append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) since this was a repeat procedure within the global period of the earlier initial surgery and did directly treat in the OR a postoperative complication arising from the initial TURBNC. Modifier 78 will indicate the treatment of a postoperative complication and allow for its payment.

Then, you should also attach modifier 52 (Reduced services) because your urologist resected residual bleeding tissue at the bladder neck but did not again perform a complete transurethral resection of the bladder neck.

Then, report 52001 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots) for the irrigation of multiple bladder clots. You should append modifier 78 to this code as well since the patient is still in the global period of the original surgery.

Additionally: Append modifier 59 (Distinct procedural service) to 52001 to break the bundling of this code with 52500. The bladder irrigations in cases such as the above always represent distinct and separate services that add to the time of and complexity of the surgery and should be billed separately.