Urology Coding Alert

Make sure you can distinguish the different SUI treatment options - mistakes could cost you nearly $800

Treatments for female stress urinary incontinence (SUI) can be lucrative - but if you don't know how your urologist chose to treat the condition, or the approach he took, you could cost your practice hundreds of dollars in reimbursement.

SUI (625.6, Stress incontinence, female) results when the urethral sphincter weakens enough that urine leaks when the patient coughs, sneezes, laughs or does any physical activity that might put pressure or stress on the bladder.

Don't confuse SUI with other incontinence disorders, says Marlene Rosen, financial manager for the Evanston Continence Center in Evanston, Ill. Female SUI is not urge incontinence (ICD-9 788.31), urinary urgency-frequency syndrome (788.41) or urinary retention (788.20). Reporting an SUI treatment linked to the wrong ICD-9 Code could prompt a denial from the insurer.

Don't Report 90901 With 51784

Biofeedback: Report CPT code 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) for the procedure of biofeedback to treat urinary incontinence.

Some coders use 90901 (Biofeedback training by any modality), however, to report the treatment. And some practices add 51784 (Electromyography studies [EMG] of anal or urethral sphincter, other than needle, any technique) when the urologist performs an EMG.

To ensure you're coding correctly, experts emphasize the danger of unbundling and advise practices to report only 90911, which already includes the EMG.

Tactic: Typically, biofeedback is done over several sessions, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 21-urologist practice in Indianapolis. "Many practices will code 51784 without 90911 for the first session of the series, and 90911 for the subsequent visits," he says.

Use 51840-51845 for Open Procedures

Surgery: Biofeedback, physical therapy (such as Kegel exercises) and medications are often insufficient for even mild cases of SUI. Then the primary mode of therapy for SUI becomes surgery. Among the surgical methods to address SUI are the Burch and MMK procedures, reported with 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple) and 51841 (... complicated [e.g., secondary repair]), says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York.

There are also needle suspension methods such as the Stamey, Raz and Gittes procedures, reported with 51845 (Abdomino-vaginal neck suspension, with or without endoscopic control [e.g., Stamey, Raz, modified Pereyra]). These procedures use an abdominal or a combined abdominal-vaginal approach.

Sling 57288 at TVT Slings

Another recent method uses a sling to create sufficient urethral compression to achieve bladder control. Through an abdominal incision, the urologist harvests a sling from the patient's own abdominal wall fascia.

TVT: A newer method uses a transvaginal tape (TVT) instead of fascia to form a sling, providing new support to tissue and featuring less morbidity than traditional sling procedures. The urologist harvests no graft material, allowing him to perform the procedure with fewer incisions - only one into the vagina. He inserts a synthetic tape between the vagina and abdominal wall to support the bladder neck.

This transvaginal procedure has become the method of choice for treating SUI. Using a TVT sling procedure is preferable because it is less invasive than Burch or MMK for SUI. The key to the success of TVT sling procedures is the polypropylene tape. Because the urologist doesn't have to harvest graft material, he makes fewer, smaller incisions, resulting in shorter recovery time.

How to do it: No matter what type of sling the urologist uses, report code 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]), says Jane Dawson, the inpatient coder for Louisiana State University Health Sciences Center Department of Urology, even though the code descriptor may not specifically mention the polypropylene tape used.

For sling removals, use 57287 (Removal or revision of sling for stress incontinence [e.g., fascia or synthetic]),  Dawson says.

Avoid Confusing 51992 With 57288

Laparoscopy: Code laparoscopic approaches to treat SUI with 51990 and 51992. To perform 51990 (Laparoscopy, surgical; urethral suspension for stress incontinence), the urologist laparoscopically 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.

Code 51992 (Laparoscopy, surgical; sling operation for stress incontinence [e.g., fascia or synthetic]) requires that sutures be placed laparoscopically from a sling under the mid-urethra to the rectus abdominus sheath.

Watch out: Code 51992 could easily be confused with 57288 because of the similar procedure descriptions. It is imperative that you take note of the approach used because it will determine whether 51992 or 57288 applies, Ferragamo says.