Urology Coding Alert

Question: The patient has had a radical prostatectomy, and the previous op note stated that my urologist performed urethrovesical anastomosis using a double-armed 3-0 V-lock suture. This was a running stitch starting posterior on the bladder neck and finishing anterior on the bladder neck. The patient now has a bladder neck contracture. My urologist sounded the urethral meatus to 28-French with Van Buren sounds. They inserted a 22-French direct visual internal urethrotomy (DVIU) scope with zero-degree lens through the urethra and advanced it to the level of the bladder neck. My urologist identified a bladder neck contracture is identified. They used a cold knife to incise the contracture at the 4 o’clock and 8 o’clock positions. My urologist incised the mucosa and underlying scar tissue. The contracture opened well at this point. My urologist was able to pass the scope through the bladder neck into the bladder. They surveyed the bladder and found it normal. My urologist then slowly removed the scope from the urethra after insertion of a guidewire. They used Heymann dilators to dilate the contracture. They dilated sequentially from 20fr to 24 fr. My urologist then placed a16-French council tip Foley catheter over the guidewire without difficulty. Finally, they inflated the balloon with 10 cc of normal saline. How should I report this procedure?

AAPC Forum Subscriber

Answer: This contracture represents a urethral stricture at the anastomosis of the bladder and urethra following a radical prostatectomy. The term “bladder neck contracture” has been used incorrectly for years as the bladder neck was removed with the radical prostatectomy. In your clinical scenario, report code 52276 (Cystourethroscopy with direct vision internal urethrotomy) for the DVIU of this anastomotic stricture.