Urology Coding Alert

Question: My urologist performed a urethroplasty and a buccal graft during the same encounter. How should I report this procedure?

California Subscriber

Answer: First, you will report the urethroplasty based on your urologist’s documentation using one of the following codes:

• 53410 – Urethroplasty, 1-stage reconstruction of male anterior urethra
• 53415 – ... transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra
• 53430 – Urethroplasty, reconstruction of female urethra.

Shift in thinking: In years past, when the surgeon performed a urethroplasty and used a graft fashioned from buccal mucosa (meaning the removal of the lining of the mouth to make a graft) you would code the procedure as 40818 (Excision of mucosa of vestibule of mouth as donor graft) for the graft excision. However, in 2011 it was suggested that instead of using 40818 for the graft, one should use code 20926 (Tissue grafts, other [e.g., paratenon, fat, dermis]), and more recently it has been suggested to use CPT® code 15240 (Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less).