Urology Coding Alert

Reader Question:

Buccal Graft Has 2 Potential Code Choices

Question: My urologist performed a urethroplasty along with a buccal graft. How should I report this procedure?

California Subscriber

Answer: First, you will report the urethroplasty based on your urologist’s documentation. Choose from these 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 (... reconstruction of female urethra).

You have two code options when reporting the graft: 20926 (Tissue grafts, other (eg, paratenon, fat, dermis)) or 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), The correct choice will depend on your physician’s documentation of the type of graft obtained. In your case, a buccal graft harvest represents a full thickness graft and is reported with CPT® code 15240. This code is used to describe the harvesting of a buccal graft.


Other Articles in this issue of

Urology Coding Alert

View All