# CPT code for exloration of fistula



## Janie751 (Jun 9, 2008)

Can anyone help me with the correct CPT code to use for transperineal exploration of a rectourethral fistula?

The other procedures are:
Cystourethroscopy (I am using 52000) and Urethroplasty (53410) with a diagnosis of 599.1.

There was another surgeon who did a procedure after this and is using 45505.

I have just started coding surgeries for a urologist, so I would appreciate any help, including any resources you might suggest that would be helpful.


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## mbort (Jun 10, 2008)

does he repair the fistula?  If so see 46470.


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## Janie751 (Jun 10, 2008)

Yes, he does repair the fistula.  I could not find the code 46470, could this be a deleted code?  Thank you for responding.


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## mbort (Jun 10, 2008)

sorry I transposed the CPT, try 46740


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## Janie751 (Jun 10, 2008)

I had to look up "imperforate" to see what it means.  This does not apply in this case because it said having no opening or lacking the usual and normal opening.  I have been looking at code 53415 and thinking it might be better than using 53410.  After looking at detailed information about this code, I am wondering if it might include the exploration.  Thank you again for responding and I welcome any other suggestions you might have.


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## FTessaBartels (Jun 10, 2008)

*22 modifier*

This is NOT my area of expertise, but ...
Have you considered adding the [22] modifier to 53410 (or 53415) to indicate the additional work of the exploration/repair of the fistula?  You would also increase your fee. Be prepared to attached supporting documentation, and possible to appeal for additional reimbursement.
F Tessa Bartels, CPC


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## Janie751 (Jun 11, 2008)

I did not think about using the modifier.  I will do some more research and see if that might work.  Thank you for taking the time to respond.


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