THE CODING EDGE® ARCHIVES

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Procedure Practice 02/15/98 - Feature Article 02/15/98
   

Procedure Practice 02/15/98:
Coding Recommendations

  
Listed below are the ICD-9-CM diagnosis and procedure codes as well as the CPT-4 procedure codes that we think properly classify this episode of treatment. Please note that modifiers, used only for physician billing purposes, have not been assigned to the CPT-4 codes. If you disagree with our suggestions or have other comments, please send an e-mail to codingedge@lagunamedsys.
   

Suggested Codes and Rationale

The patient suffers from benign prostatic hypertrophy (600, Hyperplasia of the prostate) which has caused urinary obstructive symptoms. In addition, the patient has a bladder neck contracture (596.0, Bladder neck obstruction) contributing to his urinary difficulties.

The surgery performed includes two methods of prostate tissue destruction: resection and electrovaporization. However, ICD-9-CM does not distinguish between these methods, and a single code is appropriate: 60.29, Other transurethral prostatectomy, which includes both TURP and transurethral electrovaporization of the prostate (TEVAP).

The incision of the bladder neck to relieve contracture is assigned code 57.91, Sphincterotomy of bladder. The suprapubic catheter insertion is coded 57.17, Percutaneous cystostomy.

A single CPT-4 code also captures the main components of this procedure. Under the heading "vesicle neck and prostate" select 52601, Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included). To code the suprapubic catheter insertion, use code 51040, Cystotomy, cystostomy, with drainage.

      
Bibliography - References:
CPT 98, Physicians’ Current Procedural Terminology, American Medical Association, Chicago, IL.
St. Anthony’s Illustrated ICD-9-CM Code Book, St. Anthony’s Publishing, Reston VA.		 Notice: This part of our web site was prepared to assist in understanding and maintaining good coding skills. For proper use of this feature, reference must be made to official coding guidelines when necessary. The information here presented is only to be used as a supplement to those guidelines. Laguna Medical Systems, Inc., makes no representations or guarantees as to amounts that will be paid by Medicare or other third party payers.

 

Please be aware that the Coding Edge® Archive pages are NOT retroactively updated
to reflect possible coding rules and regulation changes made after the publishing date.