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Urology Coding Alert

Reader questions:

Remember All Factors for Post-Op Procedure Coding

Published on Tue Feb 16, 2010

Question: A patient had a robotic prostatectomy for prostate cancer on Jan. 1. Then the patient started experiencing voiding problems in February. At that time my doctor did a cystoscopy to check for bladder neck contracture, which he didn't find. Is this a new problem? How should I code the second procedure? Virginia Subscriber Answer: You'll have to discuss the procedure with your urologist to see if he considers the voiding dysfunction to be a new problem or a complication of the radical surgery. Option 1: If the voiding trouble is a new problem, you should report the cystoscopy within the global of the radical prostatectomy using modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). So you will report 52000-79 (Cystourethroscopy [separate procedure]) for both Medicare and commercial payers. The diagnostic code should represent the symptom(s) that led to the cystoscopic examination. Option 2: [...]
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