Part B Insider (Multispecialty) Coding Alert

Pay attention to cyst location to help guide your coding.

For urology practices, periurethral cyst removal can be a frequently performed procedure, but the countless differences that can change the clinical presentation and the surgery can make choosing the right code a challenge. 

Take a look at four sample case studies sent in by Part B Insider readers to help guide your coding in these varied clinical situations to ensure you get it right every time. 

Check Documentation for Vaginal Periurethral Procedures

Scenario #1: My urologist documented that he excised a vaginal periurethral cyst which communicated with the urethral lumen and was diagnosed as a suburethral diverticulum. How should I report this procedure?

Answer: In this scenario, you should report 53230 (Excision of urethral diverticulum [separate procedure], female). 

Diagnosis help: You should assign a diagnosis code of 599.2 (Urethral diverticulum). Once you have to start using ICD-10 diagnosis codes , you’ll use N36.1 (Urethral diverticulum) instead of 599.2. 

Beware: If the scenario was a bit different and the urologist documented that he excised a vaginal periurethral cyst that did not communicate with the urethral lumen although it was located below the urethra and within the vaginal tissue, your coding would be different. 

In that case, the closest CPT® code that accurately describes “excision of a simple periurethral cyst not communicating with the urethral lumen” is code 57135 (Excision of vaginal cyst or tumor), says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. “However, if the cyst is located at the female urethral meatus, this may represent a Skene’s gland cyst. In this case if one excises the cyst, code CPT® 53270 (Excision or fulguration; Skene’s glands). 

For the vaginal wall cyst, report diagnostic code 623.8 (Other specified noninflammatory disorders of vagina). Additionally, for the Skene’s duct cyst append diagnosis 599.89 (Other specified disorders of urinary tract). Under ICD-10, the codes would be N89.9 (Noninflammatory disorders of vagina, unspecified) and N39.8 (Other specified disorders of urinary system), respectively. 

Tackle a Perineal Cyst Outside the Male Urethra With 53235 

Scenario #2: The urologist documents that in a male patient he excised a periurethral cyst the size of an egg that communicated with the bulbous urethral lumen. The surgeon used a perineal approach. We have never seen this in any other male patient and cannot find a specific code for the procedure. The diagnosis in this case was a urethral diverticulum in a male.

Answer: For an excision of a urethral diverticulum in a male patient, you should report 53235 (Excision of urethral diverticulum [separate procedure]; male). But if the urethral cyst is a simple cyst and does not communicate with the male urethra, you may wonder how you should code the excision of this cyst. 

“There is no specific CPT® code for this surgical procedure,” Ferragamo says. “However, the surgical approach, dissection, and surgical excision of the cyst positioned outside of the bulbous urethra is similar, but less extensive, than what would be performed for 53235 (Excision of urethral diverticulum [separate procedure]; male),” Ferragamo says. 

For the excision of a simple non communicating perineal cyst in the male you can report an unlisted code: 53899 (Unlisted procedure, urinary system). 

“To avoid using an unlisted code, I would suggest coding 53235-52 (Reduced services) to indicate a similar but less extensive operative procedure,” Ferragamo advises. “One would need to send the    insurance carrier a detailed operative report and an explanatory covering letter.” 

Diagnosis help: The diagnosis for a male diverticulum would be 599.2 for an acquired condition or 753.8 (Other specified congenital anomalies of bladder and urethra) for a congenital condition. (ICD-10: You’ll report N36.1 and Q64.79 [Other congenital malformations of bladder and urethra], respectively. 

The diagnosis for a perineal sub-urethral cyst would best be coded with ICD-9 599.84 (Other specified disorders of urethra), Ferragamo says. (ICD-10: Report N36.8 [Other specified disorders of urethra].) 

Cyst Under the Mucous Membrane Leads to 11420-11426

Scenario #3: Our urologist documented that he placed a 5-0 Prolene through the glans and used it as a glans retraction stitch. He then sharply incised the epithelium surrounding a left periurethral meatal cyst and dissected the cyst free from the surrounding tissues. He then excised the complete intact cyst and re-approximated the lateral portion of the urethral plate to the glandular epithelium using interrupted 5-0 PDS sutures.

Answer: For this case, you would report a code from the range 11420-11426 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia ...).  Because this cyst was within and under the mucous membranes and peri-urethral skin at the external meatus, this would be the proper codeset to use. Note that these codes also include a one layered closure after excision.

“The specific code one selects will depend on the size of the specimen (lesion size plus two times the smallest margin) the urologist removed, not just the size of the cyst,” Ferragamo cautions.

Diagnosis help: The diagnosis code you assign for this case should be 599.84. 

Lesion Depth Determines 53040 vs. 10060

Scenario #4: In an elderly male patient the urologist incised and drained a perineal non-communicating peri-urethral cyst/abscess secondary to a long history of a urethral stricture. The urologist suggested CPT® code 53040. However, in the operative report the abscess was not reported as deep. I suggested 10060, but the urologist said that was not correct. What is the best way to report this procedure?

Answer: Consult with the urologist, and if the lesion was indeed deep, code 53040 (Drainage of deep periurethral abscess). For a superficial abscess consider 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia]; simple or single) or 10061 (…complicated or multiple). 

Diagnosis help: You should report 682.2 (Cellulitis and abscess of trunk) as the diagnosis for a superficial perineal abscess or 597.0 (Urethral abscess) for a deep abscess. Under ICD-10, you’ll report L02.215 (Cutaneous abscess of perineum) for the superficial abscess and N34.0 (Urethral abscess) for the deep abscess.