Urology Coding Alert

Question: The urologist performed a Mercedes-Benz type incision in the perineum and dissected the subcutaneous tissue down to the bulbo-spongiosum muscle which he incised and opened. He then dissected the bulbar urethra proximally and distally. He inserted a Foley and dissected down to the stricture, transected the urethra. The doctor wrote: "The urethral was spatulated for 1 cm in each direction and overlapped. The dorsum of both segments of the urethra were fixated to the corporal bodies with 4-0 Vicryl suture, and the ends of the urethra anastomosed to each other  insuring urethral continuity." How should I code this procedure?

Pennsylvania Subscriber

Answer: Report 53410 (Urethroplasty, 1-stage reconstruction of male anterior urethra) for the repair of a bulbar stricture, which is part of the anterior urethra. This code includes the exposure of the stricture of the bulbar urethra, the excision of the urethral stricture, and a reanastomosis of the spatulated ends of the urethra via an end to end urethro-urethrostomy.

The diagnostic ICD-9 code would be 598.9 (Urethral stricture, unspecified).