Urology Coding Alert

You'll be able to report anastomosis with some procedures and not others.

If your urologist sees pediatric patients you may occasionally run across some procedures that you're not used to coding. When your urologist performs a Malone antegrade colonic enema (MACE), a Mitrofanoff procedure, or a Monti procedure, you might be left scratching your head over the proper code choice. Follow this expert guidance to ensure you're reporting the proper codes for every pediatric surgery your urologist performs.

Differentiate MACE and Mitrofanoff Before Coding

The MACE and Mitrofanoff procedures are similar, as both are used mainly in pediatric patients and involve similar anatomy, which makes coding for them a challenge.

MACE: For the MACE procedure, the physician uses the appendix or other small section of bowel to create an opening attached to the skin (a cutaneous stoma) to be used to irrigate antegrade with a catheter fecal matter from the colon.

"The MACE is generally a pediatric procedure used on children, but could also be used on adults, with chronic constipation or fecal incontinence. Usually these diagnoses are found in children who are born with spina bifida or other neurological abnormalities," explains Janell Glascock, CCS, CPMA, certified coding specialist for the Indiana University Health Physicians urology department in Indianapolis.

For the MACE procedure you will first report 50845 (Cutaneous appendico-vesicostomy), says Christy Shanley, CPC, billing manager for the University of California, Irvine department of urology. Append modifier 52 (Reduced services) because the urologist is doing part of an appendicovesicostomy (isolating the appendix but doesn't remove it from the large bowel). Then, report 44680-51 (Intestinal plication [separate procedure]; multiple procedures) for the plication of the bowel, Shanley says.

Mitrofanoff: "The Mitrofanoff [procedure] can also use the appendix, or other small bowel if the appendix is not available, and attaches one end to the bladder and the other end to the skin" in the form of a cutaneous stoma, Glascock says. "The urine can then be drained with a catheter."

Report the Mitrofanoff procedure with 50845 alone, Shanley advises.

"The Mitrofanoff appendicovesicostomy is used on patients with neurogenic bladder or urine blockage," Glascock explains. These patients are usually paraplegic individuals, children born with spina bifida, or adults with spinal cord injuries or cancer of the urinary tract."

Skip 44130 With Augmentation Cystoplasty

You may also see your urologist perform an augmentation cystoplasty in pediatric patients. An augmentation cystoplasty is an enlargement of a contracted bladderincreasing its capacity by adding a segment of bowel to the bladder. The code you'll use for this procedure is 51960 (Enterocystoplasty, including intestinal anastomosis). See the image below, which shows how an augmentation cystoplasty works.

Watch out: As noted in the code descriptor, the augmentation cystoplasty includes bowel anastomosis. This means you should not separately report 44130 (Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy [separate procedure]).

Turn to Modifiers With Ileovesicostomy Procedures

If your urologist documents that he performed an ileovesicostomy, during which he adds a segment of ileum to the bladder and then attaches the bowel to the skin forming a cutaneous stoma, then you will need to add a modifier to your coding. This is basically a nontubularized expansion of the bladder. The urologist does not open the bowel or make a bowel patch, but maintains the bowel as a tube that runs from the bladder to the skin.

Report this procedure with 51960 and append modifier 52 indicating a reduced procedure. In this case the urologist did not open up the bowel segment but added it to the bladder and to the skin as an intact tube.

Additionally: Your urologist will perform an ileostomy along with the ileovesicostomy procedure and you can separately report that procedure with 44310 (Ileostomy or jejunostomy, non-tube)

Alternative: Some experts suggest reporting this procedure using 50845, appending both modifier 22 (Increased procedural service) and modifier 52.You would add modifier 22 because the urologist fashioned the tube from the bowel and re-anastomosed one end of the bowel segment to the urinary bladder. You would add modifier 52 because the physician didn't use the appendix. Then, in addition, report44120 (Enterectomy, resection of small intestine; single resection and anastomosis).

Use Unlisted Coding for the Monti Procedure

Your urologist may also perform a "Monti" procedure, which is a variation of an ileovesicostomy used when an appendix may not be present or is unsuitable for use. There are several variations of this procedure, and there is no specific bowel segment associated with the procedure.

Bad news: There is also no specific CPT® code for the Monti procedure. You'll use the unlisted intestinal procedure code 44799 (Unlisted procedure, intestine) and the unlisted urinary procedure code 53899 (Unlisted procedure, urinary system). Benchmark the codes to 51960 and 50845.

Another alternative way to report the Monti procedure is to use 51960-52, since the urologist did not perform the full enterocystoplasty procedure. Then, also report 44316-52 (Continent ileostomy [Kock procedure] [separate procedure]) because he only did the continent ileostomy portion of the full procedure.

You could also report a Monti procedure using 50845-22-52 and 44120 as described in the previous section.