Urology Coding Alert

The only surefire approach to coding surgical procedures for stress urinary incontinence in women is to code according to the approach used by the urologist.

Stress urinary incontinence (SUI) is urine leakage that occurs during an activity such as laughing, lifting or sneezing, activities that put pressure, or stress, on the bladder, says Maureen Beckwith, CPC, urology billing specialist with the University of California at San Francisco department of urology. SUI can result from a wide variety of causes, including vaginal deliveries, obesity and even constipation, she adds.

One way to locate the correct procedure code is to use the method of approach documented by the urologist in the operative notes in addition to the patient's diagnosis, Beckwith says.

Stomach Reimbursements With 51840

One surgical method of approach used by urologists is the abdominal approach. Immediately, if the operative documentation says the sole surgical approach used was abdominal, you can narrow your code search to CPT 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple) and CPT 51841 ( complicated [e.g., secondary repair]).

The following is a summary of what 51840 involves: Using an abdominal approach, the urologist places sutures into the vaginal wall at the level of the urethra or bladder neck and anchors them to either the pubic bone, in which case the procedure is referred to as Marshall-Marchetti-Krantz (MMK), or to Cooper's ligament, designating the surgery a Burch procedure.

Shirley Fullerton, CMBS, CPC, CPC-H, practice management and coding specialist in Las Vegas, and Beckwith proffer some examples of circumstances that classify MMK and Burch procedures as complicated:

Time can really be a factor in determining whether a procedure is complicated or simple, Fullerton says. "You can also check to see if there are a lot of additional codes that are not typically required for a standard procedure."

"Even obesity can sometimes be a factor in determining whether a procedure is simple or complicated, which is why it is so important that coders review the operative report," Beckwith advises coders. "If the complication results from something like a previous surgery or injury, list the complication as the third diagnosis code."

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).

Vaginal approaches are also used to correct incontinence. When the operative notes indicate that only a vaginal approach was used, you will more than likely need code 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele).

57240 involves the plication of redundant, prolapsed tissue under the bladder and/or urethra. Correlating diagnoses for 57240 include vaginal prolapse (618.x), cystocele (618.x), urethrocele (618.x) and SUI.

CPT 2003 added one new and one revised incontinence correction code to the mix: 58293 (Vaginal hysterectomy, for uterus greater than 250 grams; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type] with or without endoscopic control). 58293 is unique in that it involves both a hysterectomy and MMK procedure performed during the same encounter often by both a urologist and a gynecologist. The procedure could be only a vaginal procedure or both a vaginal and abdominal procedure depending on which components of the procedure are performed.

For example, a 55-year-old woman with urinary incontinence presents for a combined vaginal hysterectomy procedure and incontinence correction procedure. The patient's gynecologist performs the hysterectomy, and the urologist corrects the incontinence using the Marshall-Marchetti-Krantz procedure. If the uterus weighs less than 250 gram, use revised code 58267 (Vaginal hysterectomy, for uterus 250 grams or less; with colpo-urethrocystopexy [Marshall-Marchetti-Krantz type, Pereyra type] with or without endoscopic control) appended with modifier -62 (Two surgeons). If the patient's uterus weighs greater than 250 grams, both the gynecologist and the urologist should report the new code, 58293, also each with modifier -62.

Suspend Fears of Combination Approaches With 51845, 57288 and 57289

Some incontinence procedures always involve both an abdominal and vaginal approach. These combination procedures are represented by three CPT codes:

1. 51845 (Abdomino-vaginal vesical neck suspension, with or without endoscopic control [e.g., Stamey, Raz, modified Pereyra]). In this procedure, pubocervical fascia or endopelvic fascia at the bladder neck level is suspended by sutures to the rectus abdominus muscle. Stress incontinence, cystocele and urethrocele are common diagnoses for patients undergoing 51845.

2. 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]). Sutures are placed from a sling under the mid-urethra to rectus abdominus sheath when this service is rendered. You can expect to see diagnoses of stress incontinence and intrinsic sphincter deficiency (599.82) when a urologist is performing 57288.

3. 57289 (Pereyra procedure, including anterior colporrhaphy). Look for physician documentation of pubocervical fascia or endopelvic fascia at the level of the bladder neck sutured to the rectus abdominus muscle. Likely diagnoses linked to 57289 include stress incontinence, cystocele and urethrocele.

Choose Between Two Laparoscopy Codes

Only two codes describe surgical procedures performed using a laparoscopic approach to treat SUI 51990 and 51992.

To perform 51990 (Laparoscopy, surgical; urethral suspension for stress incontinence), the urologist laparo-scopically places sutures into the vaginal wall at the level of the urethra or bladder neck and anchors them to Cooper's ligament. Don't confuse 51990 with the Burch procedure (51840 and 51841), which is an open procedure.

51992 ( sling operation for stress incontinence [e.g., fascia or synthetic]) requires that sutures be placed laparo-scopically from a sling under the mid-urethra to the rectus abdominus sheath. 51992 could easily be confused with 57288 because of the similar procedure descriptions, so it is imperative that you take note of the approach used because it will determine whether 51992 or 57288 applies.

A third minimally invasive incontinence procedure that is being performed on an outpatient basis under local anesthesia is a new type of suburethral sling, known as tension-free transvaginal tape (TVT). In a TVT procedure, a sling is placed that provides new support to tissue and has less morbidity than traditional sling procedures. No graft material is harvested, allowing the procedure to be performed with fewer incisions one into the vagina and a synthetic tape is inserted between the vagina and abdominal wall to support the bladder neck.

Terry Tropin, RHIA, CPC, CCS-P, manager, coding education for the American College of Obstetricians and Gynecologists, says the coding committee at ACOG recommends the use of 57288 for the procedure. "The traditional sling and the tape procedure both include vaginal and abdominal incisions," she says.