Urology Coding Alert

Question: The patient underwent a radical prostatectomy, and the previous op note stated that my urologist performed urethro­vesical anastomosis using a double-armed 3-0 V-lock suture. The bladder neck was sutured with a continuous running stitch, beginning at the posterior aspect and ending at the anterior aspect. Now, the patient has a bladder neck contracture. The urologist dilated the urethral meatus to 28-French using Van Buren sounds. A 22-French direct visual internal urethrotomy (DVIU) scope equipped with a zero-degree lens was then introduced through the urethra and maneuvered up to the bladder neck. My urologist identified a bladder neck contracture. The contracture was incised at the 4 o’clock and 8 o’clock positions using a cold knife. The urologist made cuts into the mucosa and the scar tissue beneath it. This effectively opened up the contracture. The urologist successfully navigated the scope from the bladder neck into the bladder. Upon examination, the bladder appeared normal. Following the

placement of a guidewire, the scope was carefully withdrawn from the urethra. Heymann dilators were then used to expand the contracture, gradually increasing in size from 20 fr to 24 fr. Subsequently, a 16-French council tip Foley catheter was smoothly inserted over the guidewire by the urologist. Finally, they inflated the balloon with 10 cc of normal saline. How should I report this procedure?

Ohio Subscriber

Answer: This contracture indicates a narrowing of the urethra at the junction of the bladder and urethra, which occurred after a radical prostatectomy. The term “bladder neck contracture” has been used incorrectly for years as the bladder neck was removed with the radical prostatectomy. In your clinical scenario, you should report code 52276 (Cystourethroscopy with direct vision internal urethrotomy) for the DVIU of this anastomotic stricture.