Urology Coding Alert

Question: How should I code the following procedure:

Operative note reads: "The urethrotome on a 12 degree scope was introduced into the urethra. In the mid-pendulous urethra, there was a small stricture that was incised, and easily passed with the scope. At the level of the membranous/prostatic urethra, there was a blind end, and there was not even a pinhole opening into the proximal urethra and bladder.

The decision at this time was to perform antegrade cystoscopy, and attempt to "cut to the light," to see if we could find a tract into the bladder. The suprapubic tube was removed by the nursing staff and the suprapubic area was prepped and draped in a sterile fashion. A flexible cystoscope was introduced into the bladder through the suprapubic tract and the bladder was examined. There was several trabeculations. There were no masses, lesions, or stones. There was some inflammation, consistent with the patient's previous history of having an indwelling suprapubic tube. The prostatic urethra was entered and a blind end was reached proximally. Attention was then turned to the distal urethra. Again the urethrotome was inserted, and the light was turned off. An attempt was made to see where the light was coming from proximally. There was some idea of where the light was and initial attempts were made to cut through dense scar tissue. Unfortunately, we were unable to connect the passages both proximally and distally, and the procedure was aborted with fear of damaging the urethra."

Illinois Subscriber

Answer: You should only report the urethrotomy. To do so, use 52276 (Cystourethroscopy with direct vision internal urethrotomy). This coding would include both the successful and unsuccessful procedures whether they were performed per urethra or via the cystostomy.

If your urologist also changed the suprapubic tube, although it was not included within the OR report you have shared, you should also bill for that procedure. You should report 51705 (Change of cystostomy tube; simple).