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Urology Coding Alert

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Bladder Neck Resection or TURP?

Published on Thu Oct 16, 2014

Question: My doctor documented the following: “I had to push the scope through the bulbous urethral stricture. There was bleeding from the bladder neck after passage of the scope. I then dilated the urethra up to 30 French with Van Buren urethral sounds and placed the bipolar resectoscope sheath. I used the bipolar resectoscope and foroblique lens to resect this tissue arising from the floor of the bladder and resected circumferentially around the bladder neck. Cautery was used for hemostasis and this specimen was removed w/ an Ellik evacuator and sent to pathology.” Should I report a TURP code for this?

North Dakota Subscriber

Answer: This does not appear to be a complete operative report, but based on what you have included it appears your urologist just resected the bladder neck. 
 
If this was a primary contracture of the bladder neck secondary to benign prostatic hyperplasia (BPH), largely forming at the bladder neck and arising from the floor of the prostate, you should report 52500 (Transurethral resection of bladder neck [separate procedure]). Attach diagnosis code 600.21 (Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms [LUTS]). 
 
If it was a bladder neck contracture secondary to previous surgery, such as a previous transurethral resection of the prostate (TURP) or a radical prostatectomy, you should instead report 52640 (Transurethral resection; of postoperative bladder neck contracture). Use diagnosis code 596.0 (Bladder neck obstruction/contracture…acquired) with 52640. 
 
Warning: The urethral dilation is bundled into both of these codes and not separately billable. 

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