Urology Coding Alert

Test your coding skills with this complicated operative report.

Bladder neck surgeries are commonplace for many urologists. But just because your urologist performs many of these procedures, that doesn't mean the coding is a piece of cake.

For example: Do you know how to report a Leadbetter -Tenago operation? See how your coding stacks up with the experts' by testing your hand at coding this case study from Jo Ann Hawtrey, CPC, CUC, financial analyst at the University of Iowa Hospitals and Clinics, Department of Urology in Iowa City.

Review the Surgical Case

Operative report: The female patient was then sterilely prepped and draped in the usual fashion. An incision was made through the previous Pfannenstiel incision, carried down to the level of the rectus fascia, which was incised transversely and elevated off the bellies of the rectus muscle, which were split in the midline and the bladder was exposed. The bladder was then opened in the midline. Prior to the start of the case a sample of urine had been obtained by catheterization through the appendicovesicostomy and a urine sample was sent for culture. GU irrigant was then instilled into the bladder. Upon opening the bladder, the urine and GU irrigant was suctioned away. The ureteral orifices were identified and cannulated with 5-French feeding tubes which were then secured in place with a suture of 5-0 chromic beneath each ureteral orifice. The incision was carried down to the level of the bladder neck, which was seen to be fixed and dilated open. The distance from the bladder neck up to the ureteral orifices was approximately 2.5 cm. I then outlined a mucosal strip with electrocautery which is to be tubularized over an 8-French catheter, which had been inserted. The tissue lateral to the strip along the bladder was then demucosalized. This left a triangular shaped area on either side of exposed muscle. The mucosal strip was then tubularized with a running suture of 5-0 Vicryl. Several interrupted sutures were placed over this to further roll the mucosal tissue in a dependent location. The mucosalized bladder muscle was then incised along the cephalad aspect on either side. At this point a right angle clamp was passed beneath the bladder neck and proximal urethra from the left side to the right side and a saline reconstituted piece of 2 cm x 10 cm SIS (small intestinal submucosa) was passed beneath the mobilized urethra.

Attention was turned back to the bladder neck reconstruction and the bladder flaps were approximated in a vest-over-pants type fashion with interrupted horizontal mattress sutures of 3-0 Vicryl. Following this, the bladder was closed with a running 3-0 Vicryl. The feeding tubes were brought out through the left side of the bladder wall and secured with a pursestring suture of 5-0 Vicryl. A 10-French straight appendicovesicostomy catheter had been passed and was secured at the skin level with a suture of nylon. The wound was irrigated with GU irrigant copiously. The SIS was crossed over along the anterior aspect of the bladder neck reconstruction and held in place with a suture of 2-0 PDS, which was also secured to the bladder neck region. Following this, a suture of 0 PDS was then used and a free needle to bring up the SIS string under tension to the fascia on either side, maintaining the crisscrossed configuration. Following this, the wound was again irrigated and the bellies of the rectus muscle were reapproximated with interrupted sutures of 3-0 Vicryl, followed by closure of the fascia with a running suture of 2-0 PDS. The wound was irrigated and Scarpa's fascia was approximated with sutures of 4-0 Vicryl, followed by reapproximation of the skin edges with a running subcuticular suture of 4-0 Monocryl. The feeding tubes were brought out the corner of the incision and the incision was infiltrated with 0.25% Marcaine. A Tegaderm dressing was placed. Anesthesia was reversed. I was present throughout the entire operation. There were no immediate complications.

Coding dilemma: How would you code this procedure? Is 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]) the best option?

Analyze the Bladder Neck Surgery

In this case the urologist performed a tubularization of the bladder neck, called the Leadbetter -Tenago operation. For this procedure, you should report 53431, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.

"Using part of the posterior bladder, the bladder base, and bladder neck tissues to reconstruct and lengthen the urethra to provide and improve urinary continence describes the Leadbetter- Tenago procedure," Ferragamo explains.

You should attach diagnosis code 599.82 (Intrinsic [urethral] sphincter deficiency [ISD]) for this portion of the procedure.

Don't Miss Coding the MMK

For the placement of the small intestinal submucosal (SIS) sling the urologist actually performed a Marshall-Marchetti-Krantz (MMK) type of urethropexy procedure. During a classic MMK, the surgeon places sutures into the vaginal wall at the level of the urethra or bladder neck and anchors them to the pubic bone.

However, in this case you can report 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple) for the MMK, because the surgeon used SIS material rather than sutures to suspend the bladder neck. You would assign diagnosis code 625.6 (Stress incontinence, female).

Skip 57288 When There's No True Sling

Code 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]) is a transvaginal sling placement and would not be the appropriate code for this surgery, Ferragamo warns.

During a transvaginal approach the surgeon places fascia or other materials at the urethrovesical junction to partially encircle and suspend the urethra, according to CPT Assistant June 2002. The surgeon pulls the ends of the sling toward the symphysis pubis and for support may fasten them to the rectus abdominus sheath.

Beware: Although there are several different types of sling procedures for the correction of urinary incontinence, there is only one CPT^{® code for the various transvaginal sling procedures performed: 57288. Use 57288 when your urologist treats incontinence with a tension-free transvaginal tape (TVT), TOT, Monarc fascial hammock, Precision Tack Transvaginal Anchor System, and a percutaneous pubovaginal sling.}