Urology Coding Alert

Question: I'm coding for a urethral diverticulectomy, cystoprostatectomy, and colon conduit urinary diversion during the same encounter. The associated diagnoses are N32.1 (Vescicointestinal fistula), D41.4 (Neoplasm of uncertain behavior of bladder), and Z85.038 (Personal history of other malignant neoplasm of large intestine). What are the correct procedure codes?

Minnesota Subscriber

Answer: The correct procedure codes for the encounter you describe are:

• Code 53235 (Excision of urethral diverticulum [separate procedure]; male) for the urethral diverticulectomy. Append diagnostic code N36.1 (Urethral diverticulum).
• Code 51590 (Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis) or 51595 (... with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes) for the cystectomy and colon conduit urinary diversion.
• Code 55840 (Prostatectomy, retropubic radical, with or without nerve sparing) for the prostatectomy.

No modifiers are needed with these CPT^® codes if the urologist provides clear documentation.