Urology Coding Alert

Question: During the procedure, my urologist made an attempt to remove a foreign object that was lodged in the urethra. To accomplish this, they performed a perineal exploration, followed by a bulbous urethra urethrotomy to widen the urethra and facilitate the extraction of the foreign body. The patient was positioned in the dorsal lithotomy position and prepared and draped in the usual manner for the procedure. The physician introduced a 22 cystoscope into the urethra. The foreign body was in the bulbous urethra, between the prostate and bladder. Attempts at removal with grasping forceps were unsuccessful, as metal to metal it would not work. My urologist then performed a perineal incision and exposed the bulbous urethra and opened the bulbocavernosus muscles. The physician retracted them laterally and located the bulbous urethral. Next, they made a urethrotomy and with an Allis clamp was able to grasp the foreign body, which was 15 cm in length. Once this was done, my urologist closed the urethra and the bulbocavernosus muscle with 4 0 Vicryl interrupted sutures. They placed a 16-Foley catheter in the bladder. Finally, they closed the skin with staples and Dermabond. I have no idea what code I should report for this procedure. How should this be coded?

RCI Subscriber

Answer: You should report 53010 (Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external) for the perineal urethrotomy, opening, and closing the perineal urethra. If the removal of the foreign prolonged the operative procedure or complicated the procedure, append modifier 22 (Increased procedural services) to the urethrotomy code.

Stephanie Stinchcomb Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coder and consultant in Summerfield, Florida, states, “Although the procedure was attempted in one approach, report the procedure finally performed to remove the foreign body.”

Remember: If your urologist made an incision in the pendulous urethra, you should report 53000 (Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra) instead.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC