Urology Coding Alert

Question: A patient had radical perineal prostatectomy. When the urologist tried to remove the drain, which had been placed subfascially, it was stuck. The patient was taken to the operating room where the physician opened the wound a third of the way and removed the drain. He then resutured the wound. How should I bill for this?


Pennsylvania Subscriber

Answer: Use 27087 (Removal of foreign body, pelvis or hip; deep [subfascial or intramuscular]) for the opening of the wound and the drain removal. Since the urologist originally placed the drain subfascially, most likely in the pelvis near the urethro-vesical anastomosis, 27087 would be appropriate.

Note: Append modifier 78 (Return to the operating room for a related procedure during the postoperative period) if the physician performed this second procedure in the global of the radical perineal prostatectomy. You would have reported the original procedure using 55810 (Prostatectomy, perineal radical), which carries a 90-day global period. Therefore, the second procedure for the drain removal would be a return to the operating room for the treatment of a complication.

Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis.