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HELP!!! Foreign Body in Urethra

  1. Question HELP!!! Foreign Body in Urethra
    Medical Coding Books
    I could really use some help with this one. What is a good CPT code to use for this???? All I have is 51702. Thanks in advance for your help. It is VERY appreciated.
    "This is a 50 year old male who inserted a clear plastic tubing into his urethra and it became lodged where he could not remove it. There is apparently a knot in the tubing at the level of the proximal pendulous urethra. He presents now to the OR for a transcutaneous transurethral incision to try and remove the foreign body. A midline 2 cm incision was made in his anterior scrotum and carried down to the corpus spongiosum. This was opened longitudinally and the mucosa was subsequently opened to identify a clear plastic tubing. This was grasped with forceps and pulled out through this small incision to reveal a knotted piece of tubing. The entire foreign body was removed without difficulty. Hemostasis was achieved. Sutures closed the mucosa, and the corpus spongiosum. A running 3-0 Vicryl was used. Buck's fascia was closed as well as the sub-q. Skin was closed with 4-0 Monocryl and Dermabond. There were no difficulties advancing an 18 French Coude catheter. There was return of 1,000 cc of bloody urine. The patient was transferred to PACU in good condition."

  2. #2
    I'm guessing that 52310(Simple) or 52315(Complicated) would be a better fit as it deals with Foreign bodies in the Urethra.

  3. #3
    I would go with 54440 plastic operation of penis for injury because this code is paid on a case by case basis. I think the surgeon did more than 52315 because they made an incision into the scrotum, which 52315 doesn't describe an incision at all. The other code that I would look at is 54115 removal foreign body from deep penile tissue.
    Kendra Songer, CPC, CUC
    San Antonio Local Chapter
    President 2016
    Treasurer 2015

  4. Default
    I'd probaby 53899 and compare to 54115. 52310 and 52315 would not be approrpriate because these codes use the cystourethroscope to retrive the foreign body. Personally, I'm not crazy about 54440 either because there is no mention that the penis was injured. Just my opinion though.

  5. Default
    I agree with Kelly, in part. As she stated, 52310 and 52315 are cystoscoopic codes and are therefore inaccurate since your doctor performed an open procedure.

    The unlisted code is the most accurate choice since there is not a CPT code to accurately convey what your physician did and the work involved. I might compare it to 53505 (Urethrorrhaphy, suture of urethral wound or injury, penile) instead of 54115 (removal of foreign body, deep penile tissue) because 53505 is specific to the urethra, and your doctor did have to suture a urethral wound or injury (his/her incision) in addition to removing the plastic tubing.

    That said, you could make a valid argument for the comparison to either code. 53505 also has a couple more RVUs so your reimbursement might turn out a little better as well. Just sayin'...

  6. #6
    Oh good point, I totally missed the incision.

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