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Urology Coding Alert

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Surgical Removal of Lower Ureteral Segment and Partial Cystectomy

Published on Mon Feb 13, 2012

Question: The doctor performed a left distal ureterectomy, partial cystectomy, ureteral reimplantation, and psaos hitch. The diagnosis he documented is "left distal ureteral tumor." How do I code this procedure?Rhode Island SubscriberAnswer: Report CPT 51565 (Cystectomy, partial, with reimplantation of ureter[s] into bladder [ureteroneocystostomy]). The catch: The psoas hitch is included (bundled) into 51565 and in this clinical scenario is not a separately billable service. Diagnosis help: You should use 189.2 (Malignant neoplasm of kidney and other and unspecific urinary organs, ureter) as your diagnosis code for this case. (Once you start using ICD-10 in 2013, you would use one of the following codes, based on the tumor location: C66.9 [Malignant neoplasm of unspecified ureter], C66.1 [... of right ureter], or C66.2 [... of left ureter]).
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