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Urology Coding Alert

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Balloon Dilation of Post-Op Bladder Neck Stricture

Published on Sun Jun 10, 2012

Question: How should I report the following procedure for a patient with a bladder neck contracture post-radical retropubic prostatectomy with inability to insert a Foley catheter:

Operative Procedure: The patient was placed in the dorsal litho position in the hospital cysto suite. The urethra was anesthetized with Lidocaine jelly. No sedation was given.

The 16 French Olympus flexible cystoscope was passed transurethrally down to the bulbous urethra where the external sphincter was seen. Proximal to this, there appeared to be a minimal amount of posterior urethra. There was bladder neck contracture present and the scope would not go into the bladder. With the scope sitting at this level, a 0.038 glide wire was passed through the scope and on into the bladder. This was curled into the bladder. This was left in place and the cystoscope removed.

An 8 French balloon dilatation catheter was then passed over the glide wire into the bladder. The cystoscope was passed transurethrally in coaxial fashion back to the posterior urethra where the bladder neck contracture was again seen. The balloon catheter was then brought back through the bladder neck and visualizing with the scope traversed the bladder neck. This was an 8 cm long balloon. The balloon was cranked up to 17 atmospheres and the balloon held in place to dilate the bladder neck for two full minutes. The balloon was deflated. The balloon catheter was removed and the cystoscope passed again in coaxial fashion next to the glidewire and on into the bladder.

Cystoscopy revealed mild trabeculations. Orfices were normal size, shape and position. No tumors, stones, diverticula or other major abnormalities were noted. The only abnormality was the FB of the glidewire curled in the bladder. There was minimal bleeding from the bladder neck. The bladder neck was dilated and it appeared to be adequately dilated. The cystoscope was removed.

A 20 French Council tip Foley catheter was then passed over the glidewire into the bladder. 10 cc of water was placed in the balloon. The glidewire was removed and drainage bag attached. The patient tolerated the procedure well and left for his room in satisfactory condition having tolerated the procedure well.

Mississipi Subscriber

Answer: You should report 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female) for the dilation of the bladder neck and also the cystoscopic examination your urologist performed. You would use this code whether he did the dilation and cystoscopy in the office under local anesthesia or in the hospital operating room (OR) with spinal or general anesthesia.

Attach 598.2 (Postoperative urethral stricture) as a primary diagnosis for this procedure. Although the diagnosis mentioned was "bladder neck contracture," in reality the bladder neck has been removed with the radical prostatectomy, and the existing "stricture" is in the urethra at the anastomosis of the urethra and bladder.

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