Question: Is the correct code for stomal stenosis dilation the unlisted-procedure code 53899, or should I bundle the procedure into the office visit?
Oregon Subscriber
Answer: If the urologist provides an E/M service as well as the dilation of the stomal stenosis, just code the E/M service alone - do not report 53899 (Unlisted procedure, urinary system).
However, if the visit only encompassed the dilation of the stomal stenosis, report the unlisted-procedure code for intestine, 44799 (Unlisted procedure, intestine).
Regardless of the procedure code, you should report 997.5 (Urinary complications) as the primary diagnosis code; you may report V55.8 (Attention to other specified artificial opening) or V44.8 (Other artificial opening status) as secondary diagnoses.