Urology Coding Alert

Question: My urologist performed a TURP (52601). One month later the patient developed gross hematuria and retention requiring cystoscopy, evacuation of blood clots and TURP. What should I code for the return to the operating room for these second procedures?


California Subscriber

Answer: You should report 52612 (Transurethral resection of prostate; first stage of two-stage resection [partial resection]) or 52614 (... second stage of two-stage resection [resection completed]) based on whether your urologist thinks (and documented) that a third TURP may be warranted in the future. Append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) because the second TURP was performed within the 90-day global period of the first TURP.

If your urologist thinks that another, possibly a third or fourth, TURP may be required within the global period of the second surgery, you should report 52612 rather than 52614, since the code descriptor for 52614 indicates a "completed resection." In this case, the physician should indicate in his operative report that the patient may need follow-up TURPs.

This documentation would support the claim that the present procedure may be part of subsequent staged procedures. If the second TURP constitutes a "completed resection," and there is no indication or suspicion that further surgery will be needed, report 52614-58 for the second TURP your urologist performed within the global period of the first.

Also report 52001 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots) for the cystoscopy. Append modifier 59 (Distinct procedural service) to 52001 to unbundle it from the TURP code.

Be sure to report ICD-9 codes 599.89 (Other specified disorders of urinary tract) for the urologist's diagnosis of gross hematuria, 596.8 (Other specified disorders of bladder) for the clot retention, and 788.20 (Retention of urine, unspecified) for the diagnosis of retention.