Urology Coding Alert

Reader Question:

53502: Confirm Gender Before Coding

Published on Mon Jan 16, 2012

Question:

We have a patient that previously had a creation of a Mitrofanoff and closure of the bladder neck. Now she is leaking urine from her urethra. My doctor does urethral ligation through a vaginal approach and excises a small segment of urethra and over sews the distal and proximal ends resulting in a tight closure of the urethra. How should I report this?

Indiana Subscriber

Answer:

You should report 51800 (Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck [anterior Y-plasty, vesical fundus resection], any procedure, with or without wedge resection of posterior vesical neck) for the closure of the urethra at the bladder neck.

Caveat: If the closure was within the urethra itself below the bladder neck, report 53502 (Urethrorrhaphy, suture of urethral wound or injury, female) since this is the closest procedure code to what your urologist performed for this female patient.

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