Ob-Gyn Coding Alert

Question: Our urogynecologist did a procedure to drain the patient's bladder before a surgery. The op note calls it a "suprapubic cystostomy." How should I report this?

Georgia Subscriber

Answer: You should report 51040 (Cystostomy, cystotomy with drainage). A suprapubic cystostomy involves the creation of a connection between the bladder and the skin, which drains urine from the bladder in individuals with obstruction of normal urinary flow. For this procedure, the urogynecologist places a catheter through the skin just above the pubic bone and into the bladder.

Caution: Be sure your physician's notes have a description of this before you submit this code. Also, remember that the patient should have a diagnosis of obstruction to establish medical necessity. For instance, the physician may have documented bladder neck obstruction (596.0, Bladder neck obstruction), or general urinary obstruction (599.60, Urinary obstruction, unspecified).