Urology Coding Alert

Alternative 1: "If the bladder neck contracture is secondary to benign prostatic hyperplasia (BPH) localized predominantly at the true bladder neck and causing obstruction, report 52450 (Transurethral incision of prostate) for the surgical incision of the bladder neck contracture," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

"Append modifier 52 (Reduced services) to indicate that the physician only made incisions at the bladder neck and not incisions along the complete prostatic urethra," he says.

Your diagnosis code in this situation would be 596.0 (Contracture [acquired] of bladder neck or vesicourethral orifice). You'll still report 52276 (Cystourethroscopy with direct vision internal urethrotomy) for the treatment of the urethral stricture located within the bulbous urethra.

For this urethral stricture, use diagnosis code 598.9 (Urethral stricture, unspecified).

Be sure to add modifier 51 (Multiple procedures) to 52276 to show that your urologist performed multiple procedures in the same operative session. "Surprisingly, CPT code 52276 is not bundled into CPT code 52450 in the CCI edits," says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist, two-urogynecologist practice in Indianapolis, so you don't need modifier 59 (Distinct procedural service).

Note: You aren't required to append modifier 51 on a Medicare claim because the carrier will automatically add them, but it doesn't hurt to do so. You may need to add 51 for private carrier claims, however.

Alternative #2: If the bladder neck contracture is secondary to an operative procedure such as a previous transurethral resection of the prostate, report 52640-52 (Transurethral resection; of postoperative bladder neck contracture; reduced services) for incising this contracture. You'll need modifier 52 to indicate that your urologist performed a reduced procedure wherein he made incisions only in the bladder neck and not a complete transurethral resection of the contracture.

Lesson learned: Be sure to read your urologist's operative reports closely, and don't just turn to 52276 when you see "bladder neck contracture."