Procedure Practice 06/15/00 - Coding Recommendations

Feature Article 06/15/00:

The Urologic System - Part 2:
The Lower Urinary Tract

Structure & Function - Symptoms& Signs - Common Disorders
Diagnostic Tests & Procedures - Common Surgical Procedures - Coding Tips
  

Following last month's discussion of the kidneys, we complete our study of the urologic system this month with a review of the lower urinary tract. Topics covered include the structure and function of the ureters, urinary bladder, and urethra, disorders affecting these organs along with common diagnostic and surgical procedures, and coding guidelines for both diagnoses and procedures.

Structure and Function

Ureters

Two ureters connect the kidneys with the urinary bladder. The ureters begin in the renal pelvis and end in the bladder. They are long, thin muscular tubes capable of wavelike rhythmic contractions known as peristalsis. Urine travels along the ureters from the kidneys to the bladder via a combination of gravity and peristalsis. Small amounts of urine are emptied into the bladder from the ureters about every 10 to 15 seconds.
 

Urinary Bladder

The bladder is a hollow, muscular, distensible sac that functions as a urine reservoir. When empty, it is situated below the peritoneal membrane and behind the symphysis pubis. When full, the bladder swells and rises into the abdominal cavity.

The bladder walls are comprised of 4 layers. The innermost layer is the mucous membrane. This membranous lining is continuous with the mucous membranes of the ureters and the urethra. The submucosa is the second layer and consists of elastic fibers of connective tissue. The third layer is involuntary smooth muscle called the detrusor muscle. The outermost layer of the upper portion of the bladder is the serosa. The lower portion of the bladder is covered by connective tissue.

The trigone is a triangular area on the floor of the bladder formed by 3 points: the entrance points of the 2 ureters and the exit point of the urethra (also called the bladder outlet). The bladder outlet is controlled by an internal sphincter muscle that contracts involuntarily to prevent bladder emptying and by an external sphincter muscle that is voluntarily controlled.
 

Urethra

The urethra carries urine from the bladder outside the body. The distal end of the urethra is the urethral meatus. Like the bladder, the urethra is lined with mucous membrane. A muscular layer aids in expelling urine. The male and female urethras differ in several ways. The female urethra is short and functions exclusively as part of the urinary system. The male urethra is longer. After exiting the urinary bladder, the male urethra passes through the prostate gland and then runs the length of the penis. The male urethra carries both urine and sperm, and thus functions as part of both the urinary and reproductive systems.

Symptoms and Signs of Urinary Disease

Urinary tract disorders manifest themselves with a variety of symptomatology. The following list contains descriptions and causes of some of the most common symptoms.

• Polyuria, or increased urine volume, may be caused by increased water intake, osmotic diuresis (e.g., glycosuria from uncontrolled diabetes mellitus), decreased vasopressin release due to hypothalamic or posterior pituitary disease, or decreased renal tubular response to ADH from hypercalcemia, K deficiency, or congenital or acquired nephrogenic diabetes insipidus (NDI).

• Oliguria, or low urine volume, tends to be acute and caused by decreased renal perfusion (prerenal factors), ureteral or bladder outlet obstruction (postrenal factors), or primary renal disease.

• Anuria, or lack of urination, may signal acute renal failure, the end stage of chronic progressive renal insufficiency, or, though rarely, renal infarction or cortical necrosis. It may also be due to reversible urinary obstruction.

• Nocturia (voiding during the night) is an abnormal, but nonspecific symptom. It may occur without disease, e.g., due to excessive fluid intake in the late evening. It may result from urine retention secondary to bladder neck obstruction. Less commonly, nocturia may reflect early renal disease and polyuria from a decrease in concentrating capacity or heart and liver failure without evidence of intrinsic urinary system disease.

• Enuresis (bed-wetting) is normal during the first 2 or 3 years of life, but later becomes a problem. It may be caused by delayed neuromuscular maturation of the lower urinary tract or organic disease, e.g., infection or distal urethral stenosis in girls, congenital posterior urethral valves in boys, or neurogenic bladder in either sex.

• Dysuria (painful urination) suggests irritation or inflammation in the bladder neck or urethra, usually due to bacterial infection. Persistent symptoms without such infection require careful evaluation of the bladder and urethra.

• Obstructive symptoms (hesitancy, straining, decrease in force and caliber of the urinary stream, terminal dribbling) are commonly due to obstruction distal to the bladder. In men, such obstruction is usually due to prostatic obstruction or less often to urethral stricture. Similar symptoms may suggest meatal stenosis in either sex.

• Vesicoureteral reflux (VUR) is the abnormal flow of urine from the bladder back into the ureters. VUR is most commonly diagnosed in infancy and childhood after the patient has a urinary tract infection (UTI). Primary VUR occurs if a child is born with an impaired valve at the ureterovesical junction. The valve does not close properly, so urine backs up from the bladder to the ureters and eventually to the kidneys. Secondary VUR occurs with blockage anywhere in the urinary system.

• Urinary retention is the abnormal holding of urine in the bladder. Normally, urination can be initiated voluntarily and the bladder empties completely. Acute urinary retention is the sudden inability to urinate, causing pain and discomfort. Causes can include an obstruction in the urinary system, stress, or neurologic problems. Chronic urinary retention refers to the persistent presence of urine left in the bladder after incomplete emptying. Common causes of chronic urinary retention are bladder muscle failure, nerve damage, or obstructions in the urinary tract.

• Urinary incontinence (an uncontrollable loss of urine) is categorized based upon the pattern of symptoms as psychogenic, urge, stress, overflow, mixed, or total incontinence. The problem may be caused by weak sphincter muscles, obstruction of urinary flow, weakened bladder muscles, nerve malfunction, stones and tumors, injury to the bladder neck, emotional disturbances, or a combination of these problems.

• Hematuria (blood in the urine) can produce red to brown discoloration depending on the amount of blood present and the acidity of the urine. Slight hematuria may cause no discoloration and may be detected only by microscope or chemical analysis. Hematuria without pain usually is due to kidney, bladder, or prostate disease.

Common Disorders

Urinary Tract Infections

The term "urinary tract infection" (UTI) covers a range of conditions in which a significant number of microorganisms colonize within a portion of the urinary tract. Microorganisms may be present only in the urine (bacteruria), or the infection may localize to a urinary organ. Infection in any part of the urinary tract may spread easily to other parts of the urinary system. UTIs may be acute or chronic.

Symptoms of an acute UTI include burning and pain with urination, frequent urination, and suprapubic or lower abdominal discomfort. The urine may also have a foul odor and be darkly colored. Chronic UTIs are usually asymptomatic except for persistent bacteruria.

Urine is sterile until it reaches the distal urethra. Bacteria usually invade the urinary tract by ascending from the urethra up the urinary tract to the bladder, ureters, or renal pelvis. Obstruction to urine flow  anywhere along the course from the kidney to the urethral meatus presents optimal conditions for advancement of infection. Free urine flow, large urine volume, complete emptying of the bladder, and acid pH are important antibacterial defenses.

Any type of microorganism introduced into the urinary tract may cause infection. However, most common are bacterial infections caused by E. coli, Enterobacter, Klebsiella, enterococci, Pseudomonas, Proteus, and Chlamydia. Neisseria gonorrhoeae, the bacterium that causes gonorrhea, can cause urethritis. Urine cultures are done to identify specific bacteria and determine appropriate antibiotic treatment. Generally, acute urinary tract infections are characterized by growth of more than 100,000 bacteria per milliliter of urine.

Infections by herpes simplex virus type 2 (HSV-2) usually affect the genital organs; however, urethral infection may occur, causing painful urination and difficulty emptying the bladder.

Fungal infections of the urinary tract are usually caused by Candida (yeast that cause candidiasis). Patients with indwelling urinary catheters often develop this type of urinary tract infection.

• Urethritis is an infection of the urethra. It may be caused by any of the above infectious agents. The infection usually begins with urethral discharge, dysuria, urgency, and increased frequency.

• Cystitis, or bladder infection, is more common in women than in men. Some women develop recurrent bladder infections. Bacteria in the vagina may travel to the urethra and then into the bladder. Bladder infections are less common in men and generally start with an infection in the urethra that progresses to the prostate and then into the bladder. A contaminated catheter or surgical instrument may also cause cystitis.

• Interstitial cystitis is a painful inflammation of the urinary bladder that occurs most commonly among middle aged women. The cause of this condition is unknown because no infecting organisms can be detected in the urine. The diagnosis is established by cystoscopy, which may reveal small superficial areas of bleeding and ulceration within the bladder. Symptoms include dysuria and increased frequency, with blood and pus often found in the urine.

• Cystitis cystica is inflammation of the urinary bladder characterized for the formation of multiple bladder wall cysts.

• Ureteritis is an infection of one or both ureters. The most common cause of ureteritis is spread of an infection either downward from the kidney or up from the bladder. Defective nerve supply to the ureters may also cause ureteritis. The poor nerve supply slows down the urine stream resulting in urinary stasis and infection.
   

Ureteral Calculi

Ureteral stones are formed in the kidney, but produce symptoms as they pass down the ureter. Severe pain occurs if a stone becomes stuck within the ureter and obstructs urinary flow. Stone formation may be secondary to metabolic disorders, UTI, or various kidney disorders, or they may be idiopathic.

Over half of ureteral stones are composed of calcium oxalate mixed with phosphate. Most of these stones are idiopathic. Other causes include ileal disease, resection or bypass, congenital or familial oxaluria, and high dietary oxalate intake.

Uric acid stones may occur in the presence of gout. Other causes include some chemotherapy drugs, leukemia, lymphoma, and high dietary purine intake.
 

Bladder Calculi

Bladder stones occur most often in the presence of residual urine infected with Proteus or staphylococci. Patients with bladder calculi usually have symptoms of chronic urinary obstruction or stasis and infection. Dysuria, increased frequency, and urgency with interruption of urine flow when the stone blocks the urethra are other common symptoms.
  

Neurogenic Bladder

This condition results from loss of normal bladder function due to damage to nerves leading to the bladder, its outlet to the urethra, or both. A neurogenic bladder may be underactive, unable to contract and empty well, or it may be overactive (spastic), emptying by uncontrolled reflexes.

An underactive bladder usually results from interruption of local nerves supplying the bladder. The most common cause in children is a defect in the spinal cord, such as spina bifida. An overactive bladder usually results from interruption of the normal control of the bladder by the spinal cord and brain.

Spinal cord injury with paraplegia or quadriplegia is the most common cause of severe neurogenic bladder. The condition may also be a late effect of a cerebrovascular accident. Other causes include diabetes mellitus, brain or spinal cord tumors, multiple sclerosis, tabes dorsalis, amyotrophic lateral sclerosis, and some congenital spinal cord disorders.

Symptoms of neurogenic bladder vary according to whether the problem is an underactive or overactive bladder. Because an underactive bladder doesn't empty well, it often stretches and becomes enlarged. Bladder infections are common in patients with underactive neurogenic bladders because the pool of residual urine in the bladder provides excellent conditions for bacterial growth. An overactive bladder may fill and empty without control and with varying degrees of warning because it contracts and empties by involuntary reflex.

With an underactive or overactive neurogenic bladder, the pressure and backflow of urine from the bladder up through the ureters may cause kidney damage. Among people with spinal cord injuries, contraction and relaxation of the bladder muscles are not coordinated, causing pressure to remain elevated within the bladder, thereby preventing drainage of urine from the kidneys.
 

Urethral Hypermobility

Hypermobility of the urethra is an underlying cause of stress urinary incontinence in many women. Hypermobility is present if the normal pelvic floor muscles no longer provide the necessary support to the urethra and bladder neck. As a result, the bladder neck moves downward when pressure is applied, and involuntary urine leakage occurs.
 

Intrinsic Sphincter Deficiency (ISD)

This term refers to weakening of the urethral sphincter muscles. As a result of this weakening the sphincter does not function normally regardless of the position of the bladder neck or urethra.
 

Obstructive Uropathy

Obstruction anywhere along the urinary tract increases pressure within the urinary tract and slows the urine flow. Urinary obstruction can distend the kidneys and also lead to urinary tract infections, urinary calculi, and decreased renal function. The site and degree of obstruction, duration of the obstruction, and the presence or absence of concomitant UTI determine the presenting symptoms of this condition.

Chronic or low-grade partial obstruction is often asymptomatic. Acute or complete ureteral obstruction produces typical renal colic and flank pain. Acute urethral obstruction causes painful distention of the bladder.

Obstructive uropathy may be due to congenital anatomic abnormalities such as ureteropelvic, ureterovesical, or urethral stricture; stones, tumors, or blood clots that block the ureter or bladder neck; extrinsic masses or adhesions that cause compression along the urinary tract; or neuromuscular disorders that cause neurogenic bladder.
 

Bladder Cancer

About 53,000 new cases of bladder cancer are diagnosed each year in the U.S. This disease affects 3 times more men than women. Smoking is the strongest single risk factor and the underlying cause of over 50% of all new cases.

Bladder cancers may be noninvasive (superficial) or invasive. Noninvasive tumors are confined to the mucosa and submucosa of the bladder walls. These tumors rarely metastasize; however, they tend to recur even after treatment. Aggressive invasive bladder tumors that have grown deep into or through the bladder wall are usually transitional cell carcinomas. These lesions often require partial or total cystectomy with local lymph node excision for complete removal.

Diagnostic Tests and Procedures

Urinalysis

Urinalysis is the best guide to intrinsic urinary tract disease and includes microscopic examination of sediment and evaluation of protein, glucose, ketones, blood, nitrites, and leukocyte esterase within the urine. Normal urine contains a low number of cells as well as other formed elements shed from the urinary tract. With disease, these cells increase and may help localize the site and type of disease or injury.

• Casts are cylindrical masses of mucoprotein in which cellular elements, protein, or fat droplets may be entrapped. They are important in distinguishing primary renal disease from diseases of the lower urinary tract.

• Proteinuria, or albuminuria, (protein in the urine) may appear constantly or only intermittently depending on the cause. Proteinuria is usually a sign of kidney disease, but it may occur normally after strenuous exercise such as long distance running.

• Glucosuria (glucose in the urine) usually indicates diabetes mellitus. If glucose continues to appear in the urine after blood glucose levels are normal, a kidney abnormality is the most likely problem.

• Ketonuria (ketones in the urine) occurs when the body breaks down fat. Starvation, uncontrolled diabetes, and occasionally alcohol intoxication can produce ketones in the urine.

• Nitrituria (nitrite in the urine) increases if bacteria are present; this test is used to diagnose a UTI quickly.

• Leukocyte esterase (an enzyme found in certain white blood cells) in the urine can be  detected by dipstick. Leukocyte esterase is a sign of inflammation, which is most commonly caused by a bacterial infection.

• Osmolality or specific gravity of urine aids in diagnosing abnormal kidney function. In one version of this test, the patient avoids fluid intake for 12 to 14 hours; in another, the patient receives an injection of the hormone vasopressin. After a period of time, the urine concentration is measured. Normally, either test should make the urine highly concentrated. However, in certain kidney disorders, the urine is abnormally dilute.
   

Urologic Imaging

These procedures are useful in determining the size and shape of the kidneys, the speed with which they empty, and the presence of calculi, cysts, and tumors within the urinary tract.

• Intravenous urography displays the kidneys and lower urinary tract. A radiopaque substance is given intravenously. The substance becomes concentrated in the kidneys usually in less than 5 minutes. Then an x-ray film is taken, which provides a picture of the kidneys and the passage of the radiopaque substance through the ureters into the bladder.

• In retrograde urography, radiopaque substances similar to those used in intravenous urography are inserted directly through a scope or catheter into the ureter. This technique provides good pictures of the bladder, ureters, and lower part of the kidneys if intravenous urography has been unsuccessful. Retrograde urography is also useful in investigating an obstruction of a ureter or in evaluating a person who is allergic to intravenous radiopaque substances. Disadvantages include the risk of infection and the need for anesthesia.

• Voiding cystourethrogram (VCUG) involves catheterization of the urinary bladder. The bladder is then distended with contrast material until the patient feels the urge to void. Voiding is then recorded on videotape with appropriate views for confirmation or exclusion of ureteric reflux and evaluation of the urethra. VCUG is used to evaluate the bladder and urethra for obstructive processes, strictures, and urine reflux.

• Radionuclide voiding cystourethrogram requires placement of a urinary catheter with instillation of technetium-99m (99mTc) pertechnetate and sterile normal saline solution via the catheter. Sequential images of the bladder and ureters are obtained during filling, postfilling, voiding, and postvoiding phases to detect retrograde vesicoureteral reflux from the bladder and/or abnormally high postvoid residual volume within the bladder.

• Ultrasound scanning uses sound waves to produce an image of anatomic structures. It can be used to study the kidneys, ureters, and bladder, with the added advantage that good pictures can be obtained even if the kidneys are functioning poorly.

• Computed tomography (CT) can distinguish solid structures from those that contain liquids, therefore CT scans are most useful in evaluating the type and extent of tumors or other masses distorting the normal urinary tract. A radiopaque substance can be injected intravenously to obtain more information. A mixture of air and the radiopaque dye pumped into the bladder during CT can clearly reveal the outline of a bladder tumor.

• Magnetic Resonance Imaging (MRI) offers information about urinary tract masses that cannot be determined by other techniques. It allows direct imaging in the transverse, coronal, and sagittal planes, thereby creating three-dimensional images of the tissue. MRI provides information about cyst fluid to help differentiate between hemorrhage and infection. In addition, MRI defines vascular structures and can reveal the extent of wall invasion by bladder cancer.
   

Urodynamic Tests

These tests evaluate the storage of urine in the bladder and the flow of urine from the bladder through the urethra by measuring the contraction of the bladder muscle as it fills and empties.

• Simple cystometrogram is a bedside evaluation of bladder function. The bladder is passively filled with sterile water via a transurethral catheter. Intravesical pressures are measured with a manometer as bladder volume increases. Information regarding bladder sensation, capacity, and contractility is obtained.

• Complex cystometrogram includes a graphic recording of the bladder pressure versus volume. The bladder is passively filled with water or gas via a transurethral catheter. Simultaneous intra-abdominal pressure is recorded via a rectal catheter. Intravesical pressures are measured as the bladder is being filled by means of a transducer. Information regarding bladder sensation, capacity, muscle tone, and contractility may be obtained in addition to the cystometrogram. Complex cystometry is useful in evaluating persistent urinary incontinence or retention felt secondary to bladder pathology.

• Gas cystometry using carbon dioxide may be used instead of water for bladder filling. This test has the advantage of being more convenient and less time-consuming. Disadvantages include inaccuracy of bladder volume measurements and inability to assess voiding cystometry.
   

Transurethral Cystoscopy/Cystoureteroscopy

To visually inspect the urethra, bladder, and ureters, the cystoscope is passed into the urethra, bladder, and ureters as indicated, and the inspection is performed. In most instances, the cystoscope used is a flexible fiberoptic instrument that conforms to the shape of the urinary channel. A wide variety of surgical procedures may also be performed transurethrally.

Common Surgical Procedures

Operative Endoscopies

Many surgical procedures are performed transurethrally via cystoscopy. Biopsies, lesion excisions, tissue destruction, and stone removal are some of the most common examples. Lithotripsy (stone destruction) may be done endoscopically via laser or ultrasound technique.
 

Cutaneous Ureteroileostomy/Ureteroileal Conduit

The surgeon creates a new urinary passage by connecting the terminal section of the small intestine (ileum) to the ureter. The distal end of this anastomosis is then brought through an incision in the abdominal wall, creating a stoma for direct emptying of urine.
 

Ureterointestinal Anastomosis/Internal Urinary Diversion

The ureter is connected to a segment of small intestine to divert urine flow. The urinary diversion is completely internal with no cutaneous fistula.
 

Percutaneous Suprapubic Cystostomy/Closed Cystotomy

In this procedure, a suprapubic incision is made to create an opening between the urinary bladder and the abdominal wall. A catheter is placed through the opening into the bladder for drainage.
 

Cystectomy

Partial or complete excision of the bladder is sometimes necessary to treat bladder cancer. Additional surgery is required to reroute urine flow. If only part of the bladder is removed, the surgeon may reattach the ureters to a new location on the bladder (ureteroneocystotomy). If the bladder is removed completely, the ureters may be anastamosed to portions of the small or large intestine, a new bladder may be constructed with portions of the small or large intestine, or the ureters may be diverted to an abdominal wall fistula.
 

Marshall Marchetti Krantz (MMK) Procedure

During this procedure, the bladder neck and urethra are separated from the back surface of the pubic bone. Sutures are placed on either side of the urethra and bladder neck, which are then elevated to a higher position. The free ends of the sutures are anchored to the surrounding cartilage and pubic bone. The MMK procedure is one of a number of surgical treatments for urinary incontinence.
 

Burch Procedure/Retropubic Urethral Suspension

This procedure is relatively simple in technique to treat stress urinary incontinence. The bladder neck is elevated by means of lateral sutures that pass through the vagina and Cooper's (pubic) ligaments. The vaginal wall and ligaments are brought together without tension, and the sutures are tied.
  

Stamey Procedure/Anterior Urethropexy

The Stamey technique is another method of bladder suspension. The procedure can be performed both vaginally or through a small suprapubic incision. A suture is used to suspend the urethra on either side of the bladder outlet. Cystoscopy is used to ensure that the urethra and bladder are not injured during the procedure.
 

Sling Procedures

These procedures are also done for urinary incontinence. Surgery may be done transvaginally or with laparoscopic assistance. Though techniques vary, the basic procedure involves creation of a hammock-type of construct that supports and elevates the bladder neck. The sling may be fashioned from the patient's vaginal tissue or abdominal fascia or made of biosynthetic material.

• During a suprapubic sling procedure, a sling is created from a strip of abdominal fascia obtained via a suprapubic incision. Another incision is made in the front of the vaginal wall, through which the surgeon grasps the sling and adjusts its tension around the bladder neck. The sling is held in place with two sutures tied to each other above the incision in the pubic fascia.

• In a transvaginal sling procedure the surgeon places two tiny anchors in the back side of the pubic bone via a small vaginal incision. Next, the sling is inserted and attached to the anchors. The sling supports the bladder neck and restores normal anatomic position of the bladder and urethra.
   

Periurethral Injections

Other alternatives to invasive, stress incontinence surgery include injectable agents that increase the bulk around the urethra. These agents compress the urethra near the bladder outlet and can improve the function of the urethral sphincter muscle. Injectable materials include collagen, fat, and synthetic compounds such as Teflon, Polytef, and Urethrin made of polytetrafluoro-ethylene (PTFE).

Coding Tips

	Assign 599.0, Urinary tract infection, site not specified, if specific documentation has not been provided regarding the site of infection. Also assign a code to identify the infecting organism if known.
	Candida infection of the urinary tract is coded 112.2.   Note: Do not code a UTI based upon lab results alone. Urine specimens are subject to contamination during collection from microorganisms surrounding the urethral meatus or by improper handling and storage. Always verify the diagnosis with the attending physician.
	Hematuria is coded 599.7.
	Female stress urinary incontinence is coded 625.6.
	Codes 788.0 through 788.9 are used if only signs and symptoms are documented. Colic, dysuria, urinary retention, unspecified urinary incontinence, frequency, oliguria, anuria, stream abnormalities, and other urinary symptoms fall into this code range. Be sure to read the inclusion and exclusion notes that accompany the specific codes in this series. A full discussion of the appropriate use of signs and symptoms codes is found at the beginning of Chapter 16, Symptoms, Signs, and Ill-Defined Conditions.
	Assign a code from the 791 subcategory, Nonspecific findings on examination of urine for abnormal urinalysis results. Again, use these codes if only signs and symptoms are documented (e.g., outpatient lab encounters) or if the symptoms represented important health problems that affected the patient's care. See the explanatory notes at the beginning of Chapter 16 for further instructions for the correct use of codes from this chapter.
	Unspecified neurogenic bladder is coded 596.54.
	Neurogenic bladder with cauda equina syndrome is coded 344.61.   Note: If neurogenic or neuropathic bladder is documented without further information, question the physician regarding the specific nature of the bladder dysfunction and its etiology. Because of the number of possible causes and the variety of manifestations, as discussed above, other codes from the 596.5x series or codes from other chapters of ICD-9-CM may be more appropriate than 596.54, Neurogenic bladder, NOS. Some examples follow: Postpartum atony of the urinary bladder due to injury caused by overdistention of the bladder during labor is coded 665.54. Postoperative atony of the bladder due to overdistention during surgery is coded 997.5. Also assign 596.4, Atony of bladder, to further specify the nature of the complication. Psychogenic spastic bladder is coded 306.59.
	To correctly code urinary obstructions, first determine the site of the obstruction, then the etiology, and finally whether or not the obstruction is a congenital disorder. Unspecified obstructive uropathy is coded 599.6. Also assign a code for any related urinary incontinence. Ureteral obstruction due to calculus is coded 592.1. Other ureteral obstruction is coded 593.4. Congenital ureteropelvic junction obstruction is coded 753.21. Code congenital urethrovesical junction obstruction 753.22. The correct code for unspecified congenital obstructive defects of the renal pelvis and ureter is 753.20.

ICD-9-CM Procedures

	Assign 56.0 for transurethral ureteral stone destruction with either high-energy shock waves or laser beam.
	Assign 56.0 and 59.95 for transurethral ultrasonic ureteral stone destruction.
	Assign 56.35 for looposcopy of an ileal conduit.
	Closed ureteral biopsy may be coded two different ways depending upon operative approach. Percutaneous biopsy is coded 56.32. Code endoscopic biopsy of the ureter 56.33.
	Cutaneous uretero-ileostomy is coded 56.51.
	Percutaneous suprapubic cystostomy is coded 57.17.
	Diagnostic cystoscopy is coded 57.32. Omit this code if the cystoscopy was used only as an operative approach. Read the exclusion notes that accompany this code for additional instructions.
	Assign 59.5 for a Burch or MMK procedure. Code a Stamey procedure 59.79.
	A suprapubic sling procedure is coded 59.4.
	Assign 59.72 for periurethral injection of collagen, fat, or Polytef to treat intrinsic sphincter deficiency.

CPT Procedures

	Ureteral endoscopy code assignment is determined by the type of approach, i.e., whether the procedure was done through an established ureterostomy or via a ureterotomy. Assign a code from the range 50951-50961 if the procedure was performed via insertion of the scope through an external stoma. Select a code from the 50970-50980 range if the scope was inserted through an incision into the ureter. If the ureterotomy represents a significant identifiable service, assign 50600-59 in addition to the endoscopy code.
	Cystoscopy and urethroscopy codes are grouped together under the term "cystourethroscopy." If the cystoscopy was diagnostic and no other procedures were performed at the time of the cystoscopic examination, assign code 52000.
	Assign 52005 for retrograde pyelogram with cystoscopy and ureteral catheterization for dye injection. Be sure to append -50 if a bilateral procedure is done.
	Cystoscopy with transurethral removal of a ureteral calculus is coded 52320.
	Fragmentation of a ureteral calculus via cystoscopy is coded 52325.   Note: Ureteral catheterization is included in both procedure codes 52320 and 52325, so do not code 52005 in addition to either of the above codes.
	Assign 52332 for cystoscopy with placement of an indwelling ureteral stent. Stent placement is assumed to be unilateral; therefore, if stents were placed in both ureters, append modifier -50 to indicate a bilateral procedure. No additional code is assigned for placement of temporary stents that were removed at the end of the major procedure.
	Indwelling ureteral stents may also be placed percutaneously via the renal pelvis or via ureterotomy. Assign 50393 for percutaneous placement and 50605 for placement via ureterotomy.
	Assign 52281 if cystoscopy with urethral dilation was performed only for documented urethral stricture or stenosis. Incidental urethral dilation to allow passage of the cystoscope is not coded.
	Dilation of a urethral stricture without endoscopy is coded 53600-53665. Note that the first 5 codes in this series are specifically for procedures performed on males, and the final 3 codes are for female patients only.
	Cystoscopy with injection of implant material for urinary incontinence is coded 51715.
	Treatment of bladder cancer via instillation of antineoplastic medication is coded 51720.
	Assign 51840 for a Burch urethropexy.
	Stamey urethropexy is coded 51845.    Note: Assign 51990 for either Burch or Stamey urethral suspension performed with laparoscopic assistance.

Practice Makes Perfect!

Are you ready for some hands-on practice? Read the patient reports on our Procedure Practice page. Assign the appropriate codes and then compare your answers with our coding recommendations. Good luck!

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The Urologic System - Part 1: The Kidneys
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If you have comments or suggestions about our code selections or about any topic on our Coding Edge® pages, please e-mail us at codingedge@lagunamedsys.com.