Urology Coding Alert

Question: I am having trouble coding a procedure. The op report reads as follows:

Procedure performed: Intraoperative abdominal exploration and cystoscopy with left ureteral catheter placement.

Preoperative diagnosis: Potential left ureteral injury.

Postoperative diagnosis: No ureteral injury noted.

Indications for surgery: The patient underwent emergency C-section and, after successful delivery of the child and closure of the uterus, there was clear effluent noted and a concern for a potential urine leak and injury to the left ureter.

Procedure description: At the time of consultation, pelvic inspection revealed that the uterus had been closed, but there appeared to be a persistent pooling of clear fluid in the left aspect of the pelvis. The pelvic anatomy was distorted secondary to previous C-section and childbirth. Methylene blue had been given, and there was good response with methylene blue draining well into the bladder. There was no evidence of methylene blue leaking into the wound.

The patient was then repositioned in the lithotomy position, cleaned, prepped and draped.

Cystoscopic examination was then performed using a 22-French rigid cystoscope. Both ureteral orifices were easily identified, and both were discharging methylene blue. A 5-French Pollack ureteral catheter was passed up and left within the left ureter. I then rescrubbed and reinvestigated the wound. The ureter was clearly far away from this area of clear fluid as was the bladder. Accordingly, it was determined this must be lymph fluid collecting and no ureteral injury had occurred. See obstetrician note for completion of dictation.

How should I code this?
Oregon Subscriber

Answer: Report 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) for the pelvic exploration. Add modifier 52 (Reduced services), as the obstetrician opened and will close the surgical incision.

Then, code 52005 (Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) for the placement of the 5-French Pollack ureteral catheter.

ICD-9 diagnostic codes should include 867.2 (Injury to pelvic organs, ureter, without mention of open wound into cavity) and V65.5 (Person with feared complaint in whom no diagnosis was made, feared condition not demonstrated).