Urology Coding Alert
Follow Documentation Details for Correct Cystotomy Code
Question: The urologist completed an intraoperative consult and then performed a cystotomy during the patient’s Cesarean section. What cystotomy code should we report?
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Answer: You have several cystotomy code choices, depending on your physician’s documentation. The options are:
Also: For the case you describe, 51040 is appropriate. Remember to use modifier 57 (Decision for surgery) with the consultation code to indicate that the consult and cystotomy were two separate services, and that the consultation exam led the urologist to perform the surgical procedure.
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