Urology Coding Alert

Don’t forget to add the proper modifiers.

Your urologist’s operative reports can be long and full of complex information and confusing terminology. If you’re coding from the simple summary at the top of the note, instead of reviewing the full report, you might be missing crucial — and billable — pieces of the surgical puzzle.

Reviewing tricky sample reports can help you hone your skills and make deciphering your own urologists’ notes easier. Our experts will walk you through the coding for this tricky sample case based on a scenario from Carmen Concepcion, CPC, practice coder at Florida Urology Associates in Orlando.

Scour the Note

Your first step is to review the urologist’s documentation:

Operative Report

POSTOPERATIVE DIAGNOSIS: Urethral diverticulum.

OPERATIONS PERFORMED:

1. Urethral diverticulum excision, female.

2. Female urethral closure.

3. Left bulbocavernosus transplant from the left labia majora

4. Diagnostic Cystoscopy.

OPERATIVE TECHNIQUE AND FINDINGS: The patient was brought to the operative suite. She was given general anesthesia. She was prepped and draped in the dorsal lithotomy position. After antibiotics, a 21-French rigid cystoscope was passed into her urethra. A bladder neck diverticulum

opening was seen at the 5 o’clock position, close to the bladder neck. Suburethral palpation revealed some cloudy fluid to drain from this. Foley catheter was then inserted and retracted. The anterior vaginal wall infiltrated with Marcaine with epinephrine. An inverted U-type incision was made on the left side of midline. The diverticulum was then dissected out with sharp and blunt dissection off of the underlying urethra. This was taken down to the neck. There was a large opening. This neck was excised and the diverticulum was completely removed. Additional mucosa at the bladder diverticulum neck was removed. 

The patient had a urethral closure in 3 layers. The mucosal layer was initially closed. Then the muscular layer of the urethra was closed initially with a 4-0 Vicryl suture, then a 3-0 Vicryl suture. The patient had this entire flap of mucosa that was overlying this excised. Dissection was performed beyond the bladder neck and this mucosa could be rotated and pulled distally to have a horizontal suture line distal to the vertical suture line for the urethral closure. Because of her concern for failure and advanced age and tissue quality, decision was made to perform a bulbocavernosus transplant from the labia majora. A left labial flap was marked. She had paucity of fat. Skin incision was made. The patient had the underlying fat mobilized. Cautery was used. The vessel inferiorly was amputated. As this was dissected, the underlying muscle had significant bleeding as a tunnel was created. The patient had cautery of this area. Several areas were over-sewn to control bleeding using 3-0 Vicryl suture. This tunnel was created more superiorly underlying the mucosa anterior to the bone and brought by having a Vicryl tagging suture, and a right angle was passed and brought anteriorly under the urethra. This completely covered the prior suture line. This flap was secured using a distal and proximal tagging suture on the right side of the midline. This flap was not on any tension. There appeared to be good hemostasis, although additional cautery was performed. There was an area of buttonholing that was over-sewn out laterally. The empty space was partially closed with several interrupted Vicryl sutures. The skin was then closed with a running Vicryl locking suture. The suburethral mucosa was then brought distally for a horizontal closure linear for a fourth layer of closure of the urethra. This suture line did not cross the prior underlying suture line and was distal. The patient had this irrigated. A final cystoscopy revealed the prior diverticulum site to be closed. Suture was seen. Care was taken to not pass the cystoscope past this area. The patient had the Foley catheter reinserted, and labial traction sutures were removed. A packing was temporarily placed. Specimen was sent to pathology including the diverticulum and the urethral neck portion. She will need to keep the catheter for 10 to 14 days.

Capture Excision First

The first code you’ll report for this procedure is 53230 (Excision of urethral diverticulum [separate procedure]; female). This represents the excision of the suburethral diverticulum.

Wording: To ensure correct coding, you should first review the operative report section titled “operations performed” in this report. You’ll see the urologist noted “urethral diverticulum excision” in that section. Then, read the operative report details (under the technique and findings header) and note the following documentation in the body of the operative report: “the diverticulum was then dissected out…was excised…the diverticulum was completely removed.” This documentation indicates that the procedure was an excision (removal) of a suburethral diverticulum and “…urethral closure in three layers…” indicates the closure of the “inverted U-type incision.”

“The correct code for this procedure in a female would, therefore, be 53230,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.

Separately Report Secondary Excision

Next, report the formation of the fat transplant as indicated first in the operations performed section of the operative report where it states a “bulbocavernosus transplant.” A clear description of this procedure follows in the urologist’s detailed documentation as follows: “skin incision was made…fat mobilized…this tunnel was created superiorly…completely covered the prior suture line…a right angle…and the transplant…was passed and brought anteriorly under the urethra.”

To properly code for this procedure report 57311 (Closure of urethrovaginal fistula; with bulbocavernosus transplant), Ferragamo says.

Don’t miss: You’ll need to attach modifier 52 (Reduced services) to 57311. You need this modifier since the urologist did not perform the full procedure because he did not perform the closure of the urethrovaginal fistula but he did performed the bulbocavernosus transplant described in the 57311 code descriptor.

You will use modifier 52  “to indicate the service was provided as described by the CPT^® code description but not fully,” says Laureen Jandroep, CPC, CPC-H, CPC-I, CPPM, CMSCS, CHCI, founder and CEO at CodingCertification.org in Oceanville, N.J. “It usually indicates the fee should be reduced.”

Finish With Coding for the Cystoscopic Examination

Finally, for this case you should report 52000 (Cystourethroscopy [separate procedure]) for the diagnostic cystoscopy.

Modifier help: Since the Correct Coding Initiative (CCI) bundles 52000 with 57311, you will need to attach a modifier. Use modifier 59 (Distinct procedural service) or modifier XU (Unusual non-overlapping service), depending on your payer’s modifier instructions.

Since the procedure was a diagnostic procedure, endoscopically finding and viewing the “urethral opening of the diverticulum at the bladder neck,” this then becomes a billable service for which you are allowed to edit and break the bundle using the modifier.