Urology Coding Alert

When your urologist states that he placed a suprapubic (SP) tube, you can decide between CPT 51040 (Cystostomy, cystotomy with drainage) and CPT 51102 (Aspiration of bladder; with insertion of suprapubic catheter) if you follow three simple guidelines.

1. Search the Documentation for Procedure Details

When determining the proper code to use for an SP tube placement procedure, you'll need to go to your urologist's documentation. Choosing between 51102 and 51040, "depends on how the tube is inserted," says Martha Guyer, CPC, patient account representative on the central charge review team at Cornerstone Healthcare in High Point, N.C.

Alice Kater, CPC, PCS, coder for Urology Associates of South Bend, Ind. agrees based on an American Urological Association (AUA) article. She says that even though 51040 and 51102 both describe SP tube insertions, they specify different placement methods, according to the article.

The other method of SP tube placement that your urologist might employ involves making a very small incision in the skin, typically only when the urologist can feel the bladder through the abdominal wall (the bladder is distended), and then using a hollow tube to "punch" into the bladder, explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

If your urologist performed a punch cystostomy rather than a formal SP cystostomy, you should report 51102 instead of 51040, Guyer says.

Key words: Anesthesia and location can clue you into the type of SP cystostomy your urologist actually performed. "A punch cystostomy is less invasive, can be performed under local anesthesia (where an open cystostomy usually requires a general or spinal anesthesia), and can be performed at the bedside," Ferragamo says. "When your urologist only reports a 'suprapubic cystostomy,' inquire as to the technique he used -- open or punch -- since each technique requires a different CPT code."

Example: In a hospital facility, the urologist is asked to see a patient who is temporarily bed ridden with a markedly distended urinary bladder and unable to void when confined to bed. The urologist decides to perform a punch cystostomy as the bladder is easily palpable and accessible from above and drainage will be required for only a short period of time. The urologist also wishes to avoid a urethral catheter and its possible complications. In this case, you should report 51102.

You should report 51040 when your urologist documents that he performed an open surgical procedure to place the SP tube, Guyer explains. Checking the details in your urologist's documentation will clue you in to whether he performed an open procedure that warrants 51040. Code 51040 describes a procedure in which the urologist creates an opening into the bladder -- also known as a cystostomy -- via an incision in the abdomen. In this open procedure, the urologist cuts through the skin, fat, fascia, and abdominal muscles, and then makes a small incision in the bladder.

He then passes the SP tube through the abdominal and bladder incisions. When the patient needs suprapubic bladder drainage, the urologist will perform an open cystostomy. The reason may be that the bladder is not palpable on abdominal examination, a prolonged period of drainage is required, or the urologist wants to avoid long term foley urethral drainage which often leads to chronic urethral infection, fistula, and stricture disease. If your urologist documents that he made a formal suprapubic incision and describes the cutting of multiple layers along with an incision of the bladder muscles and wall, you're correct to report an open cystostomy with 51040.

Example: An elderly male in urinary retention presents to your urologist. Because of a severe urethral stricture and a very enlarged prostate gland, the physician cannot insert a foley catheter via the urethra.

Also since the bladder was not palpable and long-term drainage was anticipated for this elderly patient, your urologist chose a formal open suprapubic cystostomy as definitive treatment. Therefore, you should report 51040 for this scenario.