Urology Coding Alert

Question: After informed consent, my physician inspected the meatus and phallus. At this time, there appeared to be more of the meatal skin bridge than actual true hypospadias. He dilated the meatus with the small van Buren sounds and noted that there was a meatal skin bridge. Therefore, he clamped the skin bridge with a hemostat clamp and then divided it with Metzenbaum scissors. The meatus appeared to be quite patent and open and allowed passage of the flexible cystoscope. The remainder of the anterior urethra was fairly unremarkable. The prostate itself was fairly normal in size and configuration. My physician inspected the bladder. What code should I report: 53020 or 52000? Or both?

AAPC Forum Member

Answer: You should report code 53020 (Meatotomy, cutting of meatus (separate procedure); except infant). There is procedure-to-procedure (PTP) National Correct Coding Initiative (NCCI) edit between codes 52000 (Cystourethroscopy (separate procedure)) and 53020. Code 53020 is a Column 2 code for 52000, so these procedures are bundled. However, since the modifier indicator is “0,” you cannot override this edit.