Urology Coding Alert

Question: A patient with multiple neurological issues had an indwelling Foley for so long it caused necrosis of the urethra. The patient presented for bladder neck closure and a Martius flap. How should I code this procedure?

Minnesota Subscriber

Answer: First, report 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 closure of the bladder neck.

Then, use 57311 (Closure of urethrovaginal fistula; with bulbocavernosus transplant) for your urologist's use of a Martius flap. Append modifier 52 (Reduced services) because the doctor did not also perform a closure of a urethrovaginal fistula.