Urology Coding Alert

Question: The patient has had a radical prostatectomy, and the previous op note stated urethrovesical anastomosis was performed using a double-armed 3-0 V-lock suture. This was a running stitch, starting posterior on the bladder neck and finishing anterior on the bladder neck. The patient now has a bladder neck contracture. My urologist sounded the urethral meatus to 28-French with Van Buren sounds. My urologist inserted a 22-French direct vision internal urethrotomy (DVIU) scope with zero-degree lens through the urethra and advanced it to the level of the bladder neck. They identified a bladder neck contracture. Then my urologist used a cold knife to incise the contracture at the 4 o’clock and 8 o’clock positions. They incised the mucosa and underlying scar tissue. The contracture opened well at that point. They were able to pass the scope through the bladder neck into the bladder. My urologist surveyed the bladder and found it to be normal. They then slowly removed the scope from the urethra after insertion of a guidewire. My urologist used Heyman dilators to dilate the contracture. They dilated sequentially from 20fr to 24fr. My urologist then placed a 16-French council tip Foley catheter over the guidewire without difficulty. They inflated the balloon with 10 cc of normal saline. What code should I report on my claim?

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Answer: This contracture actually represents a urethral stricture at the anastomosis of the bladder and urethra following a radical prostatectomy. The term “bladder neck contracture” has been used incorrectly for years. In this case, the patient’s bladder neck was removed with the radical prostatectomy. In this clinical scenario, you should report code 52276 (Cystourethroscopy with direct vision internal urethrotomy) for the DVIU of the anastomotic stricture with the diagnosis of urethral stricture — N99.112 (Postprocedural membranous urethral stricture, male).