Urology Coding Alert

Question: My urologist performed a urethroplasty along with a buccal graft. How should I report this procedure?

California Subscriber

Answer: First, you'll report the urethroplasty based on your urologist's documentation using one of the following codes:

• CPT 53410 - Urethroplasty, 1-stage reconstruction of male anterior urethra
• CPT 53415 --... transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra
• CPT 53430  -- ... reconstruction of female urethra.

In the past, when the surgeon performed a urethroplasty and used a graft fashioned from buccal mucosa-- meaning the removal of the lining of the mouth to make a graft -- you would report 40818 (Excision of mucosa of vestibule of mouth as donor graft) for the graft excision.

"However, in June 2011, the American Urological Association (AUA) Coding Hotline stated that instead of using 40818 for the graft, you should now use CPT® code 20926, (Tissue grafts, other [eg, paratenon, fat, dermis]) or CPT® code 15240 (Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less)," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.