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Urology Coding Alert

You Be the Coder:

Terminated Sling Procedure With Cysto Exam

Published on Tue Jan 13, 2009

Question: My urologist was scheduled to perform a sling procedure (CPT 57288 ). His operative notes state:"Initial finger dissection on the right had entered the mid-urethra rather than the periurethral space.

Removed Foley and proceeded with a cystoscopic examination; bladder was intact but was able to visualize my fingertip at 6 o'clock position in the urethra. Injury was repaired. Decision made to not proceed with the sling." How should I code this?

Virginia Subscriber

Answer: Even though the physician did not complete the sling procedure, you should report 57288 (Sling operation for stress incontinence [e.g., fascia or synthetic]). Append modifier 53 (Discontinued procedure) to indicate that your urologist terminated the procedure before completion in the interest of the well-being of the patient.

Since the physician also repaired the urethral injury, which added to the time and complexity of the surgery, you also report 53502 (Urethrorrhaphy, suture of urethral wound or injury, female).

Pitfall: Do not report just the cystoscopy and do not try to separately report a cystoscopic examination.You should consider the cystoscopic procedure bundled into 57288. Attach ICD-9 code 625.6 (Stress incontinence, female) to 57288. With 53502 use diagnostic code 867.1 (Injury to pelvic organs, bladder and urethra, with open wound into cavity).

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