Urology Coding Alert

Question: A patient presented with irritable and obstructive voiding symptons due to calculi embedded in the prostatic urethra and recurrent BPH. The patient had prior electrical vaporization and a TURP for benign disease in February. My doctor performed another TURP to eliminate recurrent obstructive prostatic tissue as well as to remove the prostatic stones.

Indiana Subscriber

Answer: Yes, the best code for you to report in this clinical scenario would be the code for transurethral resection of the prostate (TURP), which removed both the obstructing prostatic tissue and the prostatic calculi. Since the patient has a history of a prior TURP, you should report 52630 (Transurethral resection; residual or re-growth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]).

Use 600.01 (Hypertrophy [benign] of prostate with urinary obstruction and lower urinary tract symptoms [LUTS]) and 602.0 (Calculus of prostate) as the diagnosis codes for this procedure.

Pitfall: Don't be tempted to separately report the stone removal. The Correct Coding Initiative (CCI) bundles 52315 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; complicated) into 52630 and you cannot unbundle the two codes.