Urology Coding Alert

Many urologists perform female prolapse repair procedures at some point. These ventures into urogynecology can leave even the most seasoned coder scratching her head. Plus, changes in payer policies about when you can separately report mesh insertion has only muddied the waters.

But don't fret. Choosing the correct repair code is as simple as following this threestep path.

When a patient presents to your office with a prolapse of the anterior vaginal wall, which is commonly called a cystocele (618.01, Prolapse of vaginal walls without mention of uterine prolapse; cystocele, midline or 618.02, Prolapse of vaginal walls without mention of uterine prolapse; cystocele, lateral), your urologist will perform either an anterior colporrhaphy or a paravaginal defect repair. Therefore, you'll have to choose between four procedure codes, based on the procedure your surgeon uses.

For an anterior colporrhaphy, use 57240 (Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele). If the urologist or urogynecologist also repairs a urethrocele (618.03) you should not separately report its repair because it is included in the code description of 57240.

When the surgeon performs a paravaginal defect repair via an open abdominal approach, report 57284 (Paravaginal defect repair [including repair of cystocele, if performed]; open abdominal approach). For a paravaginal defect repair via vaginal approach, report 57285 (... vaginal approach). Urologists usually use paravaginal repairs for patients with a lateral cystocele (618.02).

For a laparoscopic approach, use 57423 (Paravaginal defect repair [including repair of cystocele, if performed]; laparoscopic approach), says Melanie Witt, RN, COBGC, MA, a coding expert based in Guadalupita, N.M.

When a patient has a prolapse of either the uterus or the vaginal vault, your urologist will likely perform a colpopexy, also known as a vaginal vault suspension. You have four colpopexy codes to choose from.

Choosing the proper codes means digging into the urologist's documentation to figure out the surgical approach and where the urologist anchored the suspending sutures.

Abdominal: If the urologist or urogynecologist uses an abdominal approach and attaches the vaginal vault to the sacrum, you should report the colpopexy with 57280 (Colpopexy, abdominal approach), Witt says.

Transvaginal: If the physician uses a transvaginal approach, you should report 57282 (Colpopexy, vaginal; extra-peritoneal approach [sacrospinous, iliococcygeus]).

Intraperitoneal vaginal: A third type of vaginal vault suspension involves an intraperitoneal vaginal approach. For this procedure, you would use 57283 (... intraperitoneal approach [uterosacral, levator myorrhaphy]).

Laparoscopic: If your urologist or urogynecologist incorporates a laparoscopic approach, you'll use yet another code, says Nicole Martin, CPC, owner of Innovative Coding Analysis in Coplay, Pa. In this case, you'll report 57425 (Laparoscopy, surgical, colpopexy [suspension of vaginal apex]).

Two other prolapse problems you might see cross your desk are rectoceles (618.04, Prolapse of vaginal walls without mention of uterine prolapse; rectocele) and enteroceles (618.6, Vaginal enterocele, congenital or acquired). When your urologist performs a rectocele or enterocele repair, you have additional procedure coding options to review.

What's the difference: A rectocele repair is the repair of a prolapse of the back wall of the vagina between the vagina and the rectum. Basically, a rectocele occurs when the end of the large intestine (rectum) pushes through the back wall of the vagina causing vaginal prolapse. An enterocele repair, on the other hand, is the repair of a small bowel prolapse, which occurs when the small bowel pushes against and moves the upper wall of the vagina.

For a rectocele repair, most urologists and urogynecologists perform a posterior colporrhaphy. For this type of procedure you have three coding options, depending on whether it is a single repair or a combined repair. These codes are:

• 57250 -- Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy

• 57260 -- Combined anterioposterior colporrhaphy

• 57265 -- ... with enterocele repair.

Note: Some general surgeons will instead repair the rectocele by plicating the rectal mucosa, and for this procedure the general surgeon's coder would report 45560 (Repair of rectocele [separate procedure]).

When coding for the repair of an enterocele without also repairing a cystocele and the rectocele, you must determine whether the urologist used an abdominal or a vaginal approach. For the vaginal approach, report 57268 (Repair of enterocele, vaginal approach [separate procedure]), and for the abdominal approach report 57270 (Repair of enterocele, abdominal approach [separate procedure]).

Important: Be aware that because CPT labels these enterocele repair procedures "separate procedure," the Correct Coding Initiative (CCI) bundles them into most other procedures. Check your individual payer rules before billing these codes separately if your urologist also performed a cystocele or a rectocele repair.