Urology Coding Alert

Question:

Wisconsin Subscriber

The coding for an incision of a bladder neck contracture (sometimes documented as TUIBNC) depends on the cause or etiology of the contracture.

Option 1: If the bladder neck contracture follows a radical prostatectomy, and, since the true bladder neck has been removed with the radical prostatectomy, this "contracture" actually represents a urethral stricture at the anastomosis of the bulbous urethra and bladder. In this case you would report 52276 (Cystourethroscopy with direct vision internal urethrotomy). The diagnosis should be 598.2 (Postoperative urethral stricture).

Option 2: If this is a postoperative bladder neck contracture after a transurethral resection of the prostate (TURP), report 52640 (Transurethral resection; of postoperative bladder neck contracture). Attach modifier 52 (Reduced service) since the urologist only performed an incision(s) at the bladder neck and not a full resection of the contracture. The diagnosis should be 596.0 (Bladder neck contracture).

Option 3: If the bladder neck contracture is primary, report 52450 (Transurethral incision of prostate) with modifier 52 attached to indicate that the incision(s) were made only through the bladder neck and not the complete prostatic urethra. The diagnosis should be 596.0.