Urology Coding Alert

Question: How should I report the following operative report:

Procedure:

• Exploratory laparotomy
• Complex repair of cystotomy
• Placement of fat flap between the vagina and bladder
• Left ureteral reimplant.

Diagnosis: Bladder and ureteral injury during C-section

Maine Subscriber

Answer: Report this procedure as follows:

• First, report CPT 50780 (Ureteroneocystostomy; anastomosis of single ureter to bladder) for the ureteral reimplant
• Then, report CPT 51865 (Cystorrhaphy, suture of bladder wound, injury or rupture; complicated) for the complicated bladder repair
• Finally, 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 urethra), 867.2 (Injury to ureter), and 998.2 (Accidental puncture or laceration during a procedure) as your diagnosis codes in this case.