Urology Coding Alert

With several codes to choose from, surgical female stress urinary incontinence (SUI) coding can be stressful, but your key to coding success is to focus on four details.

Rule: "You really need to read the op report to see what approach is used, for starters," says Elizabeth Hollingshead, CPC, CMC, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio. The urologist might perform multiple procedures. "Read the report thoroughly to make sure you don't miss anything and leave money on the table," she says.

If your urologist opts to perform a urethral suspension using an abdominal approach, you'll have to decide between two codes: 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple) and 51841 (... complicated [e.g., secondary repair]), says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia.

As noted in the descriptors for 51840 and 51841,you'll use these codes if you see the Marshall-Marchetti- Krantz or Burch procedure names in your urologist's documentation. "These are usually referred to as a 'Burch' or 'MMK,'" Hollingshead explains.

During the Marshall-Marchetti-Krantz (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 procedure, the surgeon anchors the sutures to Cooper's ligament.

Simple versus complicated: To determine whether the surgery qualifies as complicated -- and therefore warrants 51841 instead of 51840 -- you need to search your urologist's documentation for a few circumstances that meet the complicated requirement. "You'd use 51841, complicated, if the patient has had a prior surgery or repair or some type of anatomical issue that would result in an increase in the difficulty or time involved in the procedure," Hollingshead says.

You can consider a retropubic suspension procedure to be complicated in the following situations:

The procedure is a secondary repair

The secondary surgery involves extensive fibrosis

The procedure takes an excessive amount of time to complete due to the above anatomical problems

The procedure takes an excessive amount of time to complete because the patient is obese.

"Your urologist may opt to perform an anterior repair using a vaginal approach to surgically correct SUI. In this case, you should report 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele)," Boone says.

Bonus: During an anterior colporrhaphy procedure,your urologist might add mesh to strengthen the repair. You should report the mesh insertion using +57267 (Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site [anterior, posterior compartment], vaginal approach [List separately in addition to code for primary procedure]) in addition to 57240.

This add-on code requires no modifier or fee reduction and carries 7.16 relative value units (RVUs). That's an extra $258.37, based on the 2010 Medicare Physician Fee Schedule $36.0846 conversion factor.

Remember that you cannot bill an add-on code such as +57267 alone. You must report the code with another primary procedure -- in this case, the primary procedure is 57240.

Sometimes your urologists may use a combined vaginal and abdominal approach to perform a urethral sling operation. For those procedures, you'll report 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]). "57288 is our most used SUI correction code," Hollingshead says.

During this procedure, 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 may fasten them to the rectus abdominus sheath.

Beware: Although several types of sling procedures exist, you have only one code to use for the various sling procedures: 57288. In addition to the combined approach, you should also use 57288 when your urologist treats incontinence with a tension-free transvaginal tape (TVT). Other sling procedures you'll use 57288 for include TOT, Monarc fascial hammock, Precision Tack Transvaginal Anchor System, and a percutaneous pubovaginal sling.

Don't miss: Sometimes the physician must release or revise a sling, Hollingshead cautions. For a sling revision, release, or removal, use 57287 (Removal or revision of sling for stress incontinence [e.g., fascia or synthetic]). If the revision, release, or removal takes place within the 90-day global period of 57288, you should append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to 57287 to indicate that your urologist treated a complication (resulting from the initial sling procedure).

Some urologists may decide to treat urinary incontinence via a laparoscopic approach. If you see in the operative report that your urologist performed a laparoscopic procedure, turn to codes 51990 (Laparoscopy, surgical; urethral suspension for stress incontinence) or 51992 ( sling operation for stress incontinence [e.g., fascia or synthetic]).

The difference: 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. Report 51992 when the surgeon laparoscopically places a sling under the mid-urethra.