Urology Coding Alert

Reaching a solid diagnosis might be the trickiest part of the process.

Urethral diverticulum (UD) isn’t one of the most common conditions a urologist might see. If you find yourself coding for one of these cases – which is much more prevalent in women than in men – keep this information handy to better understand the condition and know how to report it successfully.

Quick term: A diverticulum is an abnormal pouch that opens from the intestines, bladder, esophagus, or other hollow organ.

Start by Understanding What Has Happened

In patients diagnosed with a UD, a pocket, sac, or pouch has formed off the urethra, explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. The sac fills with urine. This material becomes trapped in the sac and can become infected, leading to multiple problems or symptoms.

The exact cause of a UD is unknown, but several conditions often seemed to be linked to the diagnosis (N36.1, Urethral diverticulum). These include multiple infections that weaken the urethral wall, block urethral glands, result from congenital defects, or trauma that may have occurred during childbirth.

UD symptoms can vary from one patient to another. Some of the most common UD symptoms include:

• frequent urinary tract or bladder infections
• bloody urine
• painful sex
• pain in the pelvic area or pain during urination
• overactive bladder
• urinary incontinence
• frequent urination, particularly at night
• urinary tract blockage.

Then Turn to Treatment Options

Urinary tract infections or other issues associated with urethral diverticulum often are treated with antibiotic therapy. Urethral dilation sometimes can help alleviate symptoms as well, but antibiotics and dilation will not cure UD.

Treatment of UD can be delayed because the condition can be difficult for a physician to diagnose because the associated symptoms are often nonspecific.

A high index of suspicion and careful examination of the anterior vaginal wall in women with unexplained urinary symptoms remains the key to making a diagnosis.

“An anterior vaginal wall mass with leakage of material from the external meatus on palpation of the mass is often appreciated and diagnostic of the problem,” says Ferragamo. High resolution MR imaging is the best for ascertaining anatomical details and relationship with the urethra.

Even when the urologist diagnoses UD, some patients with minimal symptoms often decline surgery to correct the problem. For those who opt for surgery, your first-line coding options are differentiated by male and female:

• 53230 – Excision of urethral diverticulum (separate procedure); female
• 53235 – … male.

Code 53230 for female diverticulum excision has a total RVU assignment of 17.51. The procedure is more complex in males, so code 53235 has an RVU worth of 18.29. Female surgery is more frequently performed as urethral diverticula are more frequently found in the female than in males.

What happens: In females, the urologist makes a longitudinal incision into the anterior vaginal wall to approach the urethra and the urethral diverticulum. He then dissects the diverticular sac and separates the diverticulum from the urethra and surrounding vaginal tissue. He identifies the diverticular neck and connection to the urethra, sutures this closed, removes the diverticulum, and closes any urethral defect with sutures. In most cases, he will insert a catheter into the urethra for several days to promote healing.

A diverticulum in the male is approached through a ventral incision over the pendulous urethra and the perineum using the same surgical techniques as above to remove the diverticulum and close the connecting diverticular neck into the urethra.

Most diverticulum in both males and females arise from the floor of the urethra and are often designated as a” sub-urethral” diverticulum.

Don’t Miss the Marsupialization Alternative

In some situations, the urologist will recommend the patient undergoes marsupialization of the diverticulum rather than excision when the diverticulum is small and located in the distal urethra. This operation is coded with CPT^® code 53240 (Marsupialization of urethral diverticulum, male or female), which has a total RUVs of 12.28.

During the procedure, the surgeon creates an opening in a diverticulum and evacuates the contents. Then he surgically creates a pouch or sac over the neck of the diverticulum. Over time the lining of the pouch will eventually separate from the membrane and the defect fills in by granulation.

Double Check for Other Procedure Possibilities

Before finalizing the claim with 53230, 53235, or 53240, verify that the urologist did not perform any other procedures during the operative session that can be reported separately.

Example: When evaluating a patient for a diverticulum, a urologist may perform the following diagnostic studies which are not bundled and also billable:

• 52204 – Cystourethroscopy and biopsy (s) (of the bladder or urethra)
• 51610 – Injection procedure for retrograde urethro­cystography
• 74450 – Urethrocystography, retrograde, radiological supervision and interpretation.

Cystourethroscopy (52000) is also often performed to locate the opening of the diverticulum within the urethra, but this CPT code is bundled into the above diverticulectomy codes, and because the bundle cannot be broken/undone with any modifier, a separate charge for the cystoscopic examination cannot be made.