Urology Coding Alert

Question: Another physician called my doctor into the operating room. During a gynecologic procedure the other physician discovered a bladder perforation at the dome. After consultation, my urologist performed an exploratory laparotomy, excised a portion of what appeared to be diseased bladder, and repaired the bladder in two layers. He then placed contrast into the bladder and confirmed a water-tight anastomosis. He also placed a Foley catheter. What are the proper CPT and ICD-9 codes for this procedure?

California Subscriber

Answer: You should first report 51550 (Cystectomy, partial; simple) for the partial bladder resection to remove what appeared to be "diseased bladder" and to close the bladder perforation.

Next, report 51700 (Bladder irrigation, simple, lavage and/or installation) for the instillation of contrast material to test the water-tight closure of the bladder. Finally, report 74430-26 (Cystography, minimum of three views, radiological supervision and interpretation; professional component) for the interpretation of the cystogram if your urologist documented that he performed and did interpret the cystogram.

You should attach diagnosis code 867.0 (Injury of pelvic organs; bladder and/or urethra, without mention of open wound into cavity) for this case.