Urology Coding Alert

Question: My urologist performed a Holmium laser prostatectomy via a “BRIDGE” technique. What is a BRIDGE technique prostatectomy, and how do I code this procedure?

New York Subscriber

Answer: The BRIDGE technique is a surgical innovation combining Holmium laser enucleation (HoLEP) and Holmium ablation (HoLAP) techniques during one Holmium laser prostatectomy procedure. In this technique the urologist first incises (vaporizes) the bladder neck with the Holmium laser at the 5 and 7 o’clock positions, down to the bladder neck fibers. Then, the urologist extends each incision distally to the verumontanum, avoiding the external urinary sphincter.

Next, the urologist enucleates the middle lobe using the laser to the proximal prostatic urethra and partially detaches it from the bladder neck. Using the Holmium laser, the urologist then morcellates the middle lobe (adenoma) into smaller pieces within the prostatic fossa, which are now detached completely from their attachments to the bladder neck and float into the bladder to be subsequently removed by irrigation. The urologist then completely ablates (vaporizes) the smaller lateral lobes with no fragment production.

As a second technique, your urologist may perform morcellation (fragmentation) of a completely detached large adenoma within the cavity of the bladder using a morcellator, endoscopic scissors, or a transurethral resection. Under either of these circumstances, you should report 52649 (Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed]).

Alternative: However, if the urologist removes the enucleated and detached adenoma in whole from the bladder by basket extraction or grasping forceps without fragmentation into smaller pieces, you should use 52648 (Laser vaporization of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral recection of prostate are included if performed]). The Correct Coding Initiative (CCI) bundles the removal of the adenoma using a grasping forceps or basket (52310 or 52315) in 52648 and you cannot override the bundle with any modifier.

Warning: Do not use 52649 if no morcellation or other fragmentation of the adenoma takes place.

Remember: CCI bundles component code 52648 into the comprehensive code 52649, and you cannot override this edit with any modifier. Because of this edit you cannot bill these two codes during the same operative encounter.

However, the appropriate coding for such a combination Holmium laser procedure is dependent on the predominant technique your urologist employs in the procedure and documents in the medical record. If the predominant procedure is enucleation, as it is in the above scenario, then the proper code would be 52649. If the predominant technique employed is ablation, then the proper code would be 52648.

Note: Morcellation of tissue as described as part of 52649, in reality, has little influence in the choice of the proper laser code. The enucleation technique includes fragmentation of the enucleated tissues whether the urologist performs it within the prostatic fossa by the laser itself or within the bladder with a tissue morcellator.