Chapter 20 Step by Step Medical Coding
When coding cystourethroscopies with dilation ask these questions:
1. is patient male or female? 2. Is this an initial or subsequent procedure? 3. was general or spinal anesthesia used?
Vesical Neck and Prostate(52400-52700) are based on
Approach
Exploratory=
Diagnostic
Anatomic divisions of Urinary System
Kidney, Ureters, Bladder, and Urethra
Notes before 52000 indicate that included are:
Meatotomy, Urethral calibration, Urethral dilation, Urethroscopy, Cystoscopy, Urethral catheterization
Male Genital System subsections
Penis, testis, epididymis, tunics vaginalis,scrotom, vas deferens, spermatic cord, seminal vesicles
What are some possible causes of urine flow obstruction?
Renal calculus, narrowing of the ureter, cysts, etc
51102
Suprapubic catheter placement
What is the term for removal of a calculus from the ureter?
Ureterolithotomy
Procedures on prostate is either in
Urinary or Male Genital system
Instillation of anticarcinogenic agent via
a catheter for bladder cancer. Retention time included
Introduction category usually has
a radiology component
Allotransplantation
a transplant between two people who are not related
Always code urodynamic code in addition to
all other cysto codes if both are performed
Introduction includes:
aspirations, catheters and injections for radiography, insertion of guidewires, and tube changes
Remove calculus
based on location of upper third, middle third, or lower third
Why is a urethral stent placed?
because of a UVJ obstruction
Use modifier -50 for
bilateral transplantation procedure
Laparoscopic approach of ureterolithotomy
billed with 50945
open approach of ureterolithotomy
billed with 51060
Commonly used codes in Male genital excision are
biopsy and circumcision
further divided based on purpose
biopsy or removal of foreign body/calculus
Ureterectomy(50650, 50660)
bladder cuff excision or total excision
extensive destruction
can be by any method
Cystotomies and Cystectomies(51520-51596)
codes divided based on extent of procedure
TURP
codes for transurethral resection of the prostate
50225
complicated nephrectomy because of previous surgery on same kidney
Laparoscopic ablation of renal includes
cyst, lesion, cryoablation, and percutaneous
Repair (51800-51980) includes
cystoplasty, cystourethroplasty, Vesicourethropexy/urethropexy(urinary incontinence)
What is the basis for the subheadings for the Male genital system codes?
divided into anatomical subheadings
If something is found on the exploratory procedure and a corrective procedure ensues
do not bill for the exploratory procedure
Kidney endoscopy codes for procedures are assigned according to approach
either a previously established stoma is used as an entry point or an incision is used
Renal endoscopy codes divided by
established connection between kidney and body exterior (50551-50562) Nephrotomy or pyelotomy(50570-50580)
TURBT(52234-52240)
excision or fulguration of bladder tumor
Nephrotomy(50045)
exploration of inside of kidney. no definitive procedure
Male Genital System Destruction codes are divided on
extent:simple or extensive and method of destruction
Cystotomy(51020-51045)
for lesion destruction, insertion of radioactive material, fulguration(use of electrical current)
Ureter Endoscopy codes(50951-50980)
for procedure through established stoma
Bladder Injection Procedures (51600-51610)
for urethrocystography. Radiographic S&I reported separately
Urachal Cyst
found between the umbilicus and bladder dome and is often found in young children when the cyst becomes infected
transurethral surgery involving Ureter/pelvis (52320-52355)
includes insertion and removal of temporary stents
The bladder subheading (51020-51597)
includes many usual services, for example incision and excision, but it also contains urodynamic category
Nephrostomy(50040)
insertion of catheter into kidney with one end in kidney and one end outside body
Percutaneous lithotripsy
insertion of probe to pulverize calculus
52000
is assigned for IVP, if appropriate
52005
is assigned for retrograde pyelogram
What are the benefits of ESWL?
it breaks up large stones and makes them easier to pass
What does the UPJ connect?
it connects the renal pelvis to the ureter
Excision of the bladder cuff is only coded if
it is the only procedure performed. if it performed with another procedure, it is bundled in.
Ureter (50600-50980)
laparoscopy codes describe surgical procedures. these codes can be bilateral or unilateral
renal endoscopic procedures are
less invasive than open procedures and often can be performed on an outpatient basis
The bladder section has
many bundled codes Ex: Urethral dilation is included with insertion of cystoscope
Urethroplasty may be
one or two stage
Nephrectomy
partial or total(radical) excision of kidney
Nephrectomy record documentation should say if procedure was
partial or total, laparoscopic, or open, and if any structures were removed
Urinary system is further divided by
procedure(incision, excision, introduction and repair)
UroDynamics(51725-51798)
procedures relate to motion and flow of urine(motor and sensory function)
Nephrolithotomy(50060-50075)
removal of calculus
radical nephrectomy
removal of fascia, fatty tissue, regional lymph node, adrenal gland
Percutaneous nephrostolithotomy (PCNL) or pyelostolithotomy
removal of kidney calculus
Aspirations are done to
remove urine from the bladder. if imaging guidance is used, this is separately reportable.
Cystoplasty
repair of the bladder
Cystourethroplasty
repair of the bladder and the urethra
Pyeloplasty
repair of ureteropelvic junction(UPJ)
Incision/Biopsy codes of the Ureter
report open procedures
Ureter endoscopy codes are used to
report procedures that involve an established stoma
Introduction category-Ureter
reports injections, manometric(measures pressure) studies, change of stents/tubes
The carcinogenic agent that is instilled in the bladder is
retained for a period of time with the patient lying down. the agent is then drained and the treatment is concluded.
Kidney located in
retroperitoneal area
Catheterization can be
simple(Foley) or complicated (anatomical anomaly of catheter fracture)
Laparoscopy(51990-51999)
stress incontinence procedures
Urethra Manipulation
stretches of narrowed passage
What is the basis for the division of the category subheadings?
subheadings are divided by procedure
Manometric studies
tests to measure kidney and ureter flow and pressure
Nephrectomy codes are based on
the complexity and extent of the procedure
Ablation
the cutting away or erosion of tissue
If a procedure starts as a diagnostic procedure and turns into a surgical procedure
the diagnostic procedure is not billed
What are the codes in the laparoscopy category based on?
the extent of the procedure
What subheading under the male genital system has the greatest number of codes?
the penis subheading because a large number of repair codes are included here
What is the bladder cuff?
the tissue that connects the ureter to the bladder
If the physician performs only the professional component of the service
then the modifier -26 is added to the code
The incision category for the penis is different from the integumentary system section because
they are used for deep incision
Autotransplantation
transfer of tissue from one part of a persons body to another part of his or her body
Ureter is divided by
type of procedure(incision or excision, introduction, repair, laparoscopy, or endoscopy)
the codes for male genital system biopsy are located
under the anatomical subheading to which they refer
ESWL
use of shock waves to fragment calculus
urodynamics
used to diagnose urine flow obstructions
A cystoscopy is a
visual examination of urinary bladder by means of cystoscope
What is the reason for renal exploration?
when the cause of the patients conditions is unknown
The urethra dilation codes under the manipulation category are based on
whether its initial or subsequent and if the patient is Male or female
Urethra codes are divided based on
whether the patient is male or female
Most cystoscopy procedures have
zero global days
retroperitoneal area diagnostic procedure
49010
Retroperitoneal abscess
49060
closure of fistula(abnormal opening)
50520-50526 it can either abdominal or thoracic
Laparoscopic placement of urethral stent
50947, 50948
Endoscopy-Cystoscopy, Urethroscopy, Cystourethroscopy
52000-52010 has many combination codes
Transurethral Surgery involving Urethra/bladder
52204-52318
other approaches are reported with
55801-55845
