Urology Coding Alert

Question: The urologist scheduled surgery to repair a bilateral ureteral injury. His documentation shows he performed “open repair of both ureteral injuries,” “repair of vaginal cuff,” and “cystoscopic bilateral ureteral stent placements.” The remaining urinary tract seemed intact. He sutured closed the vaginal cuff. What codes do you recommend?

Maryland Subscriber

Answer: You should report three procedure codes for this encounter:

• 57200 (Colporrhaphy, suture of injury of vagina [nonobstetrical]) for the vaginal cuff repair
• 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent [e.g., Gibbons or double-J type]) with modifier 50 (Bilateral procedure) for the cystoscopy and bilateral ureteral stent placement
• 50900 (Ureterorrhaphy, suture of ureter (separate procedure)) with modifier 50 for the bilateral ureteral repair.