Urology Coding Alert

Question: My physician is planning a pubo-vaginal sling on a patient who had one done two years ago. The sling has failed, so it must be redone. The urologist has noted that the primary diagnosis is female urinary incontinence. What procedure and diagnosis codes should I be using?


Minnesota Subscriber

Answer: For the repeat sling procedure, you should report CPT code 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]).
 
Caution: The removal of the previously inserted sling, represented by 57287 (Removal or revision of sling for stress incontinence [e.g., fascia or synthetic]), includes 57288, according to the National Correct Coding Initiative edits, and you cannot break this edit using a modifier. However, when the urologist both places a new sling and removes an old sling, you should report only 57288 for the repeat sling operation outside of the original global period.

Diagnosis help: The diagnosis code you should report for the reoccurring stress incontinence the patient must now have is 625.6 (Stress incontinence, female). You should also use 998.89 (Other specified complications of procedures, not elsewhere classified; other specified complications) as a secondary diagnosis code to indicate a previously failed procedure.