Question: The urologist performed an open suprapubic tube placement and an open retropubic bladder neck closure. The diagnosis is NGB. What codes should we use?
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Answer: First, report CPT® code 51800 (Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck [anterior Y-plasty, vesical fundus resection], any procedure, with or without wedge resection of posterior vesical neck) for the bladder neck closure, followed by 51040 (Cystostomy, cystotomy with drainage) for the suprapubic cystostomy tube. Include supporting diagnosis N31.8 (Other neuromuscular dysfunction of bladder), otherwise known as neurogenic bladder dysfunction (NGB).