Urology Coding Alert

Scour the documentation for pertinent details to direct your coding. 

Stress incontinence is a common diagnosis urologists and urogynecologists treat in their female patients. But just because you see these diagnoses frequently, doesn’t mean the associated procedure coding is always a breeze.

If you think of incontinence procedures falling into three categories, you can quickly focus your code search. Your physician can choose from the following surgical options for incontinence, says Nina Mutone, MD, MPH, urogynecologist with Urology of Indiana in Indianapolis:

1. Retropubic suspension

2. Needle procedures

3. Bulking injection

4. Slings.

Start by determining the category the surgery fall into and then follow these four tips to guide you to the proper code no matter which incontinence procedure your physician performs.

Tip: Sometimes looking at the diagnosis code your urologist assign can also help you determine the incontinence procedure code to report. See the chart on page 36 for a list of diagnosis codes associated with these incontinence procedures.

1. Determine Simple vs. Complicated for MMK and Burch

In the recent past one of the most common treatments for a female patient with urinary incontinence was an open retropubic suspension, also known as a colposuspension. You have two suspension codes to choose from.

If the op report states that the sole surgical approach was abdominal and the surgeon performed either a Marshall-Marchetti-Krantz (MMK) or Burch procedure, you can immediately limit your search to two codes: 51840 (Anterior vesicourethropexy, or urethropexy [e.g., Marshall-Marchetti-Krantz, Burch]; simple) and 51841 (… complicated [e.g., secondary repair]).

“Both are performed via abdominal retropubic approach and involve suspension stitches placed in the periurethral vaginal wall bilaterally,” Mutone explains. “MMK uses the symphysis pubis as the anchoring point and Burch uses Cooper’s ligament.”

Simple or complicated: Your physician’s documentation is the key to choosing 51840 or 51841. You can consider a retropubic suspension procedure to be complicated in the following situations, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.:

·         If it is a secondary repair following a previous surgery.

·         If there is extensive bleeding during surgery.

·         If the patient has adhesions from a previous surgery.

·         If the patient has significant vaginal prolapse.

·         If the procedure takes an excessive amount of time to complete.

·         If the patient is obese.

·         If the surgeon encounters aberrant anatomy.

“There could be other reasons,” Witt stresses. “The important thing is that the MD has documented why this procedure was complicated.”

2. Needle Suspension Procedures Mean 51845

Needle suspensions, also known as urethropexy, are another way physicians can treat female incontinence. “Needle suspensions are done through a combined vaginal/suprapubic approach,” Mutone explains. “The vaginal wall is opened and dissected out laterally, and a skin incision is made suprapubically. A needle is brought down from the suprapubic incision on both sides of the vagina and used to suspend the periurethral vaginal tissue to the abdominal wall behind the pubic bone.”

According to Mutone, needle suspensions are “uncommon now due to very low long-term success rates.” However, if your physician does perform a needle suspension, look to the documentation details for specifics on which code to report. If he documents performing a Stamey, Raz, Gittes or modified Pereyra needle procedure, you should report 51845 (Abdomino-vaginal vesical neck suspension, with or without endoscopic control [e.g., Stamey, Raz, modified Pereyra]), according to Witt. For a Pereyra procedure, use 57289 (Pereyra procedure, including anterior colporrhaphy), she adds.

3. Bulking Injections Equal 51715

When your urologist uses Coaptite^® injections to treat stress incontinence, you would use CPT^® code 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck).

Don’t miss: For the implant material you should also report HCPCS code L8606 (Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies) times the number of syringes used to the payer who is reimbursing for the 51715 procedure code.

4. Choose 57288 Regardless of Sling Type

With the technology available today, sling procedures are often the treatment of choice for incontinence cases. There are several types of sling procedures. However, there is just one code: 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]). You will report 57288 regardless of the type of sling procedure your surgeon performs, Witt explains. “The unifying factor is that a material is placed under the urethra. The type of material, the approach, and the anchoring systems all differ,” Mutone agrees.

For example, the urologist or urogynecologist might use a combined vaginal and abdominal approach to perform a suburethral sling. During this procedure, the urologist places fascia or other materials at the urethrovesical junction to encircle and suspend the urethra. The surgeon then pulls the ends of the sling toward the symphysis pubis and fastens them to the rectus abdominus sheath. You will report 57288 for this procedure.

Additionally: You should use 57288 when your urologist treats incontinence with tension-free transvaginal tape (TVT) as well. In this case, the surgeon places the TVT sling, providing new support to tissue with less morbidity than traditional sling procedures. This procedure has become a popular option because it is less invasive for the patient. Other sling procedures include TOT, Monarc subfascial hammock, Precision Tack Transvaginal Anchor System, and a percutaneous pubovaginal sling.

Pointer: Even though the code descriptor for 57288 doesn’t mention a particular type of sling, that doesn’t mean the code is not correct for that procedure. The bottom line is that you will report all sling placement procedures using 57288. For a sling revision or removal, use 57287 (Removal or revision of sling for stress incontinence [e.g., fascia or synthetic]).

4. Laparoscopy Leads to 51990, 51992

While laparoscopic treatments are not as common now for stress incontinence as they have been in the past, your urologist may choose to perform them occasionally. In those cases, you will turn to 51990 (Laparoscopy, surgical; urethral suspension for stress incontinence) and 51992 (… sling operation for stress incontinence [e.g., fascia or synthetic]).

If your urologist laparoscopically places sutures into the vaginal wall at the level of the urethra or bladder neck and anchors them to Cooper’s ligament, choose 51990, Mutone explains. You should report 51992 when he laparoscopically places the sutures from a sling under the mid-urethra to the rectus abdominus sheath, although this procedure is “almost unheard of,” Mutone says.