Urology Coding Alert

Question: My urologist re-admitted a patient who had a suture of a urethral wound, 53502 (Urethrorrhaphy, suture of urethral wound or injury, female) performed on 8/28/21 and was having issues with urine leaking from the closure. Even though it was a new hospitalization, this would still be considered a post-op visit, because it’s a complication of the surgery, right?

AAPC Forum Member

Answer: Some private and commercial carriers will pay for the hospital visits (treatment of complications) if clearly documented, but Medicare will not. For the private or commercial carriers who will reimburse for this service, you should append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) and include a separate diagnosis for the complication.