Urology Coding Alert

Question: A patient had a sling procedure (CPT 57288 ). She then needed a revision (CPT 57287 ) during the global period of the initial sling procedure. Is this billable? And if so, does it need a modifier?

Washington Subscriber

Answer: You can, and should, report the revision. Youll use 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]) for the original procedure, as you noted. For the revision within the 90-day global period, report 57287 (Removal or revision of sling for stress incontinence [e.g., fascia or synthetic]) for the second procedure. Append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to 57287 to indicate that your urologist is correcting a complication associated with the original surgery.

This is a fairly common clinical occurrence. Many times the urologist must return the patient to the operating room to revise the sling because it is now too tight, and the patient goes from being incontinent to not being able to urinate at all. In such a case, the urologist will incise the implanted sling in the midline and free it up, allowing the patient to void. The sling still provides support but is no longer restrictive. This is a revision of the sling and is also a treatment of a complication from the original surgery. Therefore, you can report 57287-78.

Diagnosis help: Assign diagnosis code 996.76 (Other complications of internal [biological] [synthetic] prosthetic device, implant, and graft; due to genitourinary device, implant, and graft) for the revision procedure. The diagnosis for the first procedure most likely was 625.6 (Stress incontinence, female).