Urology Coding Alert

Question: My urologist performed attempted removal of a urethral foreign body. He performed a perineal exploration with bulbous urethra urethrotomy and extraction of the foreign body. My urologist placed the patient in the dorsal lithotomy position prepped and draped in the usual manner. He introduced a 22 cystoscope into the urethra. The foreign body was in the bulbous urethra, almost in the prostate and bladder. Attempts at removal with grasping forceps were unsuccessful, as metal to metal it would not work. My urologist then performed a perineal incision and exposed the bulbous urethra and opened the bulbocavernosus muscles. He retracted them laterally and located the bulbous urethral. Next, he made a urethrotomy and with an Allis clamp was able to grasp the foreign body, which was 15 cm in length. Once this was done, my urologist closed the urethra and the bulbocavernosus muscle with 4 0 Vicryl interrupted sutures. He placed a 16-Foley catheter in the bladder. Finally, he closed the skin with staples and Dermabond. I have no idea what code I should report for this procedure. Can you help me?

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AAPC Forum Subscriber

Answer: You should report 53010 (Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external) for the perineal urethrotomy, opening, and closing the perineal urethra. If the removal of the foreign prolonged the operative procedure or complicated the procedure, append modifier 22 (Increased procedural services) to the urethrotomy code.

Don’t miss: If your urologist made an incision in the pendulous urethra, you should report 53000 (Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra) instead.