Urology Coding Alert

Question: The urologist documented that he performed an endoscopic injection of implant material into the submucosal tissues of the urethra at the bladder neck for a female patient. What would be the appropriate code to use? I've been told both 51715 and 53899 are appropriate.

Florida Subscriber

Answer: You should report 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck) for this procedure. This code accurately describes the procedure your urologist documented.

Why: If no precise procedure or service code exists,you should report the service using the appropriate unlisted procedure or service code, state the CPT Instructions for Use in the CPT manual. CPT includes unlisted-procedure codes to allow you to report procedures for which there is no specific CPT descriptor available. However, when there is an established CPT code that accurately describes the services your urologist performs,you should report that code rather than an unlisted code.

Note: Append ICD-9 code 599.82 (Intrinsic [urethral] sphincter deficiency [ISD]) as the primary diagnosis and 625.6 (Stress incontinence, female) or 788.33 (Mixed incontinence, [male] [female]) as secondary diagnoses.