Urology Coding Alert

Question: The doctor performed a left distal ureterectomy, partial cystectomy, ureteral reimplantation, and psaos hitch. The diagnosis he documented is "left distal ureteral tumor." How do I code this procedure?

Rhode Island Subscriber

Answer: Report CPT 51565 (Cystectomy, partial, with reimplantation of ureter[s] into bladder [ureteroneocystostomy]).

The catch: The psoas hitch is included (bundled) into 51565 and in this clinical scenario is not a separately billable service.

Diagnosis help: You should use 189.2 (Malignant neoplasm of kidney and other and unspecific urinary organs, ureter) as your diagnosis code for this case. (Once you start using ICD-10 in 2013, you would use one of the following codes, based on the tumor location: C66.9 [Malignant neoplasm of unspecified ureter], C66.1 [... of right ureter], or C66.2 [... of left ureter]).