Urology Coding Alert

Question: Our urologist replaced a regular Foley catheter with an open SP cystotomy tube placement. The female patient had an eroded urethra and was totally incontinent. During the same procedure, the doctor transvaginally closed her urethra. How do I code this procedure?

Maine Subscriber

Answer: First report 51800 (Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck [anterior Y-plasty, vesical fundus resection], any procedure, with or without wedge resection of posterior vesical neck) for the vaginal closure of the urethra and bladder neck.

Then, report 51040 (Cystostomy, cystotomy with drainage) for the suprapubic (SP) cystostomy. Append modifier 51 (Multiple procedures) to 51040 to show that the procedures were separate (if the payer requires modifier 51). The modifier indicates to the payer that the urologist performed both procedures during the same session. You can expect half the global reimbursement for codes with modifier 51 attached.

Caveat: If your urologist performed a punch cystostomy rather than a formal SP cystostomy, you should then report 51102 (Aspiration of bladder; with insertion of suprapubic catheter).