Urology Coding Alert
Release of Suburethral Scar Tissue
Question: Our urologist saw a female patient who had urethral stenosis and scarring after an anterior vaginal repair. Via a vaginal approach he surgically excised the scar tissue and performed a urethrolysis in the mid urethral region to allow urethral laxity and further mobility. How do we code this?
South Carolina Subscriber
Answer: The exact code will depend on the documentation, such as the cause of development of the scar tissue, or the approach the surgeon used while performing the scar tissue release. The information you’ve given seems to point to 53500 (Urethrolysis, transvaginal, secondary, open, including cystourethroscopy [e.g., postsurgical obstruction, scarring]) for lysis of adhesions and a urethrolysis in the urethral region. However, verify this by the surgeon’s notes before submitting the claim.
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