Urology Coding Alert

Answer: You can't correctly code the two procedures you have described unless you know the motivation for the subsequent cystostomy.

You can start by coding the percutaneous cystostomy using 51010 (Aspiration of bladder; with insertion of suprapubic catheter), which is usually reported for patients who present in urgent urinary retention.

Next code the open suprapubic cystostomy using Cpt 51040 (Cystostomy, cystotomy with drainage). Though not indicated in your question, if the formal suprapubic procedure was performed a few days later but within the 10-day global period of 51010, you will need to append a modifier to 51040.

If 51040 was performed to correct complications, such as bleeding or tube dislodgement that resulted from 51010, you will need to append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the open cystostomy. On the other hand, if the trocar cystostomy, 51010, did not function properly and did not allow adequate drainage, append modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to 51040 to indicate that the second procedure to correct the original problem was more extensive than the first. Use of modifier -58 will allow full payment for code 51040.