Urology Coding Alert

Question: Which code should I report for excision of a duplicate urethra? The urologist is doing an epispadias repair along with the excision. I'm looking at 54380 for the epispadias repair, but I'm stuck on the urethra excision. Any suggestions?

Tennessee Subscriber

Answer: The answer depends on the nature of the "duplicate urethra." Was this a true duplicate urethra, or was it a diverticular opening and a diverticular-like structure of the native incomplete urethra?

If it was a diverticular opening, add CPT code 53235 (Excision of urethral diverticulum [separate procedure]; male) for the diverticular removal to the epispadias repair code 54380 (Plastic operation on penis for epispadias distal to external sphincter).

If the patient had a true duplicate urethra, however, consider CPT code 53215-52 (Urethrectomy, total, including cystostomy; male; reduced services), appending modifier -52 if the urologist did not perform a suprapubic cystostomy and the excised urethra constituted only a duplicated anterior urethra.