Urology Coding Alert

Tip: If your physician uses a sling, you only have 1 code to represent the procedure

Editor's note: This is the first article in a series on urogynecological procedures. See the next issue of Urology Coding Alert for an article on prolapse surgeries.

Female urinary incontinence is a common condition that urologists and urogynecologists surgically treat, and your key to sorting through the various coding options for these procedures is to decipher the surgical approach your physician took.

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. Your physician can choose from the following surgical options for incontinence:

• retropubic suspension
• needle procedures
• slings.

Choose CPT 51840 , 51841 for Retropubic Urethropexy

Your urologist may choose a retropubic suspension to treat a female patient with urinary incontinence. If the op 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.

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 later in this issue for more information.

Another surgical method your urologist may opt for is needle suspension. Physicians don't use this procedure as often as they used to because it hasn't worked well, Mutone says. 

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

52788 Is Your Answer for Slings

Urologists and urogynecologists often perform sling procedures on female patients with 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]).

If your physician uses a combined vaginal and abdominal approach to perform a suburethral sling operation, you would report 57288. During this procedure, the urologist places fascia or other materials at the urethrovesical junction to encircle and suspend the urethra, Mutone says. 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 urologist 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 urologist uses, report 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 57287 (Removal or revision of sling for stress incontinence [e.g., fascia or synthetic]).

51990, 51992 Are Your Laparoscopy Options

Some urologists decide to treat urinary incontinence via laparoscopic approaches. If you see in the op 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 [e.g., fascia or synthetic]), Witt says.

If your urologist 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: Urologists 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.