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Bladder, Ureter Repair After Surgical Damage
Published on Fri Jul 15, 2011
Question: How should I report the following operative report:Procedure:Exploratory laparotomyComplex repair of cystotomyPlacement of fat flap between the vagina and bladderLeft ureteral reimplant.Diagnosis: Bladder and ureteral injury during C-sectionMaine SubscriberAnswer: Report this procedure as follows: First, report CPT 50780 (Ureteroneocystostomy; anastomosis of single ureter to bladder) for the ureteral reimplantThen, report CPT 51865 (Cystorrhaphy, suture of bladder wound, injury or rupture; complicated) for the complicated bladder repairFinally, report 20926 (Tissue grafts, other [eg, paratenon, fat, dermis]) for the advancement of the flap or +49905 (Omental flap, intra-abdominal [List separately in addition to code for primary procedure]) for the flap if the flap is an abdominal omental flap.Modifier help: If your payer requires modifier 51 (Multiple procedures), remember to append 51 to 51865 and 20926. 49905 is an add-on code and therefore, you should never append modifier 51 or reduce the 49905 global fee.Diagnosis coding: Use 867.0 (Injury to bladder and/or [...]