Part B Insider (Multispecialty) Coding Alert

Hint:  Your physician's approach falls into one of three categories

The causes of female urinary incontinence are many, so you may be overwhelmed by treatment coding options. But if you can correctly decipher both the treatment and the cause, you'll easily choose the best code every time. Here's how.

From both a clinical and coding perspective, it helps to think of incontinence procedures in categories, says Nina Mutone, MD, medical director of the urogynecology division at St. Vincent's Hospital in Indianapolis, Ind. Your physician can choose from the following surgical options for incontinence:

• Retropubic suspension
• Needle procedures
• Slings

Choose 51840 , 51841 For Retropubic Urethropexy

Your physician may choose a retropubic suspension to treat a female patient with urinary incontinence. If the operative report states that the sole surgical approach was abdominal and the physician performed either a Marshall-Marchetti-Krantz (MMK) or Burch procedure, you can immediately narrow your search to two codes: 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple) and 51841 (... complicated [e.g., secondary repair]).

During an MMK procedure, the surgeon places sutures into the vaginal wall at the level of the urethra or bladder neck and anchors them to the pubic bone. For a Burch sling procedure, the surgeon would anchor the sutures to the Cooper's ligament.

How to choose: Your physician's documentation is the key to choosing 51840 or 51841. You can consider a retropubic suspension procedure to be complicated in the following situations:

• If it is a secondary repair following a previous surgery
• If there is extensive bleeding during surgery
• If the patient has adhesions from a previous surgery
• If the patient has vaginal prolapse
• If the procedure takes an excessive amount of time to complete
• If the patient is obese
• If the surgeon encounters aberrant anatomy

Tip: A good way to double-check your code selection is to determine whether the patient's diagnosis correlates to procedures 51840 and 51841. Possible diagnoses for MMK and Burch procedures include stress incontinence (625.6), vaginal prolapse (618.x) and mixed incontinence (788.33). See the chart on the following page for more information.

Don't Let 51845 Needle You

Another surgical method your physician may opt for is needle suspension. Physicians don't use these procedures as often anymore because they haven't proven to be especially efficacious, Mutone says. 

If your physician does perform a Stamey, Raz, Gittes or modified Pereya needle procedure, however, you should report code 51845 (Abdomino-vaginal vesical neck suspension, with or without endoscopic control [e.g., Stamey, Raz, modified Pereyra]) or 57289 (Pereya procedure, including anterior colporrhaphy) for a Pereyra procedure, says Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M. Physicians perform these procedures using either an abdominal or a combined abdominal-vaginal approach.

52788 Is Your Answer For Slings

Physicians often perform sling procedures on female patients suffering from incontinence. Although several types of sling procedures exist, you only have one code to use: 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]).

Do this: If your physician uses a combined vaginal and abdominal approach to perform a suburethral sling operation, you would report 57288. During this procedure, the surgeon places fascia or other materials at the urethrovesical junction to encircle and suspend the urethra, according to Mutone. The surgeon then pulls the ends of the sling toward the symphysis pubis and fastens them to the rectus abdominus sheath.

In addition to the combined approach, you should use 57288 when your surgeon treats incontinence with tension-free transvaginal tape (TVT). In this case, the surgeon places the TVT sling, providing new support to tissue with less morbidity than traditional sling procedures. This procedure has become a popular option because it is less invasive for the patient. Other sling procedures include TOT, Monarc subfascial hammock, Precision Tack Transvaginal Anchor System, and a percutaneous pubovaginal sling.

The bottom line: No matter what type of sling your physician uses, report code 57288, Witt says, even though the code descriptor may not specifically mention the type of sling he used.

Note: For a sling revision or removal, use code 57287 (Removal or revision of sling for stress incontinence [eg, fascia or synthetic]).

51990, 51992 Are Your Laparoscopy Options

Some physicians decide to treat urinary incontinence via laparoscopic approaches. If you see in the operative report that your physician performed a laparoscopic procedure, turn to codes 51990 (Laparoscopy, surgical; urethral suspension for stress incontinence) and 51992 (... sling operation for stress incontinence [eg, fascia or synthetic), advises Witt.

Take your pick: If your physician laparoscopically places sutures into the vaginal wall at the level of the urethra or bladder neck and anchors them to Cooper's ligament, choose 51990. You should report 51992 when he laparoscopically places the sutures from a sling under the mid-urethra to the rectus abdominus sheath.
 
Note: Physicians don't use laparoscopic approaches as commonly today as they used to. "Laparoscopic treatments for incontinence became less popular when TVT and other midurethral slings took off," Mutone says.