Ob-Gyn Coding Alert

Question: My ob-gyn performed a sling operation for stress incontinence and a cystourethroscopy. How should he report it - 57288 and 52000-59?
Tennessee Subscriber

Answer: The only code for a sling procedure for stress urinary incontinence is 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]). However, you can only report a cystourethroscopy if you have a medical indication for doing so, such as bleeding or possible leakage.
 
If the surgeon performed the cystourethroscopy to check for suture placement, this procedure is part of good surgical technique and not separately billable. You would only use modifier -59 (Distinct procedural service) if the payer normally bundles this procedure. If that is the case, you could only use modifier -59 if you meet one of the criteria for its use, such as when the ob-gyn performs the procedures during a different encounter, or separate incision, among others, according to CPT (see CPT Appendix A for a full description of when to use modifier -59).
 
If this procedure is billable under any other circumstance, the cystourethroscopy is simply a multiple procedure and you would use modifier -51 (Multiple procedures) instead.