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CHAPTER 20

URINARY AND MALE GENITAL SYSTEMS

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Urinary System (1 of 2)

Anatomic divisions

Kidney

Ureters

Bladder

Urethra

Procedures on prostate in either Urinary or Male Genital System

Figure 20.1

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Procedures involving the urinary system are reported using codes 50010-53899.

What are the four subheadings for the urinary system codes? (The codes are arranged anatomically by four subheadings: kidney, ureters, bladder, and urethra.)

Urinary System (2 of 2)

Further divided by procedure

Incision

Excision

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On what basis are the category codes organized? (Arranged by procedure—incision, excision, introduction, and repair.)

Kidney (50010-50593)

Endoscopy codes for procedures done through

Previously established stoma

Incision

Most cystoscopy procedures have zero global days

A cystoscopy is a visual examination of urinary bladder by means of cystoscope

Figure 20.6

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The Kidney subheading includes codes 50010-50593.

Endoscopy codes are assigned according to approach—either a previously established stoma is used as an entry point (which is created by placing a catheter through the skin and into the kidney), or an incision is used.

When coding endoscopy procedures, the coder must identify the entry method in order to assign the right code.

Incision (50010-50135)

Caution:

Kidney located in retroperitoneal area

Each has codes for procedures

Renal exploration

Kidney diagnostic procedure (50010), no further procedures performed

Retroperitoneal area diagnostic procedure (49010)

Renal abscess

Kidney abscess (50020)

If radiological supervision and interpretation were performed see 75989

Retroperitoneal abscess (49060)

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What is the reason for renal exploration? (When the cause of the patient’s condition is unknown)

If something is found on the exploratory procedure and a corrective procedure ensues, do not bill for the exploratory procedure.

Exploratory = Diagnostic.

Procedures (1 of 2)

Nephrostomy (50040): Insertion of catheter into kidney with one end in kidney and one end outside body

Nephrotomy (50045): Exploration of inside of kidney

No definitive procedure

Verify all CCI code edits to prevent unbundling

Nephrolithotomy (50060-50075): Removal of calculus

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It is important to know the difference in these terms and understand that the surgeon may start out performing a nephrotomy to explore the kidney and find a reason for the patient’s urinary obstruction, and the procedure then becomes a nephrolithotomy when a calculus is found.

Procedures (2 of 2)

ESWL: Use of shock waves to fragment calculus

Percutaneous lithotripsy: Insertion of probe to pulverize calculus

Basket attached to probe and pulverized calculus removed

Percutaneous nephrostolithotomy (PCNL) or pyelostolithotomy

Removal of kidney calculus

Figure 20.3

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How is ESWL performed? (The patient is placed on a water-filled cushion on his or her back, and while the patient is under general anesthesia, shock waves are targeted to the stones, which are pulverized with repeated shocks.

What is the benefit of this? (It breaks up large stones and makes them easier to pass.)

Excision (50200-50290)

Nephrectomy: Partial or total (radical) excision of kidney (50220-50240)

Radical: Removal of fascia, fatty tissue, regional lymph node, adrenal gland

Nephrectomy medical record documentation should indicate if procedure was partial or total, laparoscopic, or open, and if any structures were removed

Code 50225 describes a complicated nephrectomy because of previous surgery on same kidney

Ablation

Cryosurgery, 50250

Laparoscope, 50542

Percutaneous, 50593

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What is a nephrectomy? (Removal of a kidney)

Nephrectomy codes are based on the complexity and extent of the procedure.

What does ablation mean? (The cutting away or erosion of tissue)

Renal Transplant (50300-50380)

Backbench work

Retrieval of organ

Deceased (50300)

Living (50320, open; 50547, laparoscopy)

Preparation of organ

Deceased (50323)

Living (50325)

Transplantation

Without nephrectomy, 50360

With nephrectomy, 50365

Add modifier -50 for bilateral procedure

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Allotransplantation is a transplant between two people who are not related.

Autotransplantation is a transfer of tissue from one part of a person’s body to another part of his or her body.

Introduction (50382-50435)

Aspirations

Catheters and injections for radiography

Insertion of guidewires

Tube changes

Usually reported with radiology component

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What additional component is usually reported with procedures in the Introduction category? (These are usually reported with a Radiology component.)

These category codes include extensive notes, which should be read by coders before they code in this area.

Repair (50400-50540)

Pyeloplasty

Repair of ureteropelvic junction (UPJ)

Simple 50400

Complicated 50405

Closure of fistula (abnormal opening)

50520-50526

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What does the UPJ connect? (It connects the renal pelvis to the ureter.)

Usually congenital defect but it can be acquired.

Closure of a fistula depends on the approach. It will either be abdominal or thoracic.

Laparoscopy (50541-50549)

Ablation of renal

Cyst (50541)

Lesion (50542)

Cryoablation (50250)

Percutaneous (50593)

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What are the codes in this category based on? (The extent of the procedure)

Endoscopy (50551-50580)

Renal endoscopy codes divided by

Established connection between kidney and body exterior (50551-50562)

Nephrotomy or pyelotomy (50570-50580)

Further divided based on purpose

Biopsy

Removal of foreign body/calculus

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Renal Endoscopic procedures are less invasive than open procedures and often can be performed on an outpatient basis.

Ureter

Divided based on type of procedure

Incision

Excision

Laparoscopy codes describe surgical procedures

Codes may be bilateral or unilateral

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The Ureter subheading includes codes 50600-50980.

On what basis are the Ureter subheading codes divided? (Codes are divided according to type of procedure—incision, excision, introduction, repair, laparoscopy, or endoscopy.)

The endoscopy codes in this subheading (50951-50980) are used to report procedures that involve an established stoma.

Incision/Biopsy (50600-50630)

Report open procedures

Explore or drain (50600)

Insert indwelling stent (50605)

Remove calculus (50610-50630)

Based on location of upper third, middle third, or lower third

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What is the medical term for the removal of a calculus from the ureter? (Ureterolithotomy)

Laparoscopic approach billed with 50945.

Open approach billed with 51060.

Excision and Introduction (50650-50690)

Excision

Ureterectomy (50650, 50660)

Bladder cuff excision or total excision

Introduction

Reports injections, manometric (measures pressure) studies, change of stents/tubes

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Bladder cuff is the tissue that connects the ureter to the bladder.

Excision of the bladder cuff is only coded if it is the only procedure performed. If it is performed in conjunction with another procedure, it is bundled in and not separately reportable.

Manometric studies are tests to measure kidney and ureter flow and pressure.

Laparoscopy and Endoscopy(50945-50980)

Laparoscopic placement of ureteral stent (50947, 50948)

Endoscopy codes (50951-50980) for procedure through established stoma

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Why is a urethral stent placed? (Because of a UVJ obstruction)

The Endoscopy Category can be intimidating due to the medical terminology used in this category.

Great knowledge of medical terminology will increase your coding accuracy.

Bladder

Many bundled codes

Example: Urethral dilation is included with insertion of cystoscope

Read all descriptions carefully for site, technique, and reason for procedure

Figure 20.8

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The Bladder subheading (51020-51597) includes many usual services, for example, incision and excision, but it also contains urodynamic category.

When coding from this subheading, it will help to know the anatomy of the bladder.

Incision and Excision

Incision (51020-51080)

Cystotomy (51020-51045) for lesion destruction, insertion of radioactive material, fulguration (use of electrical current)

Suprapubic catheter placement, 51102

Excision (51500-51597)

Cystotomies and cystectomies (51520-51596)

Codes divided based on extent of procedure

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Aspirations are done to remove urine from the bladder.

If imaging guidance is used, this is separately reportable.

A urachal cyst is found between the umbilicus and bladder dome and is often found in young children when the cyst becomes infected.

Introduction (51600-51720)

Injection procedures (51600-51610) for urethrocystography

Radiographic S&I reported separately

Instillation of anticarcinogenic agent via a catheter for bladder cancer

Retention time included

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The catheterization can be simple (Foley) or complicated (Anatomical anomaly or catheter fracture)

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.

Urodynamics (51725-51798)

Procedures relate to motion and flow of urine (motor and sensory function)

Used to diagnose urine flow obstructions

Bundled: All usual, necessary instruments, equipment, supplies, and technical assistance

Always code urodynamic code in addition to all other cysto codes if both are performed

Modifier -51 is reported for multiple procedures

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What is urodynamics? (Motion and flow of urine)

What are some possible causes of urine flow obstruction? (Renal calculus, narrowing of the ureter, cysts, etc.)

If the physician performs only the professional component of the service (e.g., interpretation), then the modifier -26 is added to the code.

Repair and Laparoscopy

Repair (51800-51980)

Cystoplasty

Cystourethroplasty

Vesicourethropexy/urethropexy (urinary incontinence)

Laparoscopy (51990-51999)

Stress incontinence procedures

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Define: Cystoplasty—Repair of the bladder

Cystourethroplasty—Repair of the bladder and the urethra

Urethropexy—Repair for urinary incontinence

Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy (1 of 2)

52000-52010

Many combination codes

Notes before 52000 indicate that included are:

Meatotomy

Urethral calibration

Urethral dilation

Urethroscopy

Cystoscopy

Ureteral catheterization, etc.

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Take special care in this category to read codes carefully. All of the procedures included are found in the description.

Many third-party payers have a list of edits on codes that cannot be reported with other codes.

Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy (2 of 2)

52000 is assigned for IVP, if appropriate

52005 is assigned for retrograde pyelogram

When coding cystourethroscopies with dilation ask following questions:

Is patient male or female?

Is this an initial or subsequent procedure?

Was general or spinal anesthesia used?

Additional time/effort of second procedure

Modifier -22

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Transurethral Surgery (52204-52355)

Urethra/bladder, 52204-52318

TURBT (52234-52240)

Excision or fulguration of bladder tumor

Ureter/pelvis, 52320-52355

Includes insertion and removal of temporary stents

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Divided by codes for urethra/bladder and ureter/pelvis.

As in other areas, if a procedure starts as a diagnostic procedure and turns into a surgical procedure, the diagnostic procedure is not billed.

Vesical Neck and Prostate (52400-52700)

Contains codes for transurethral resection of the prostate (TURP)

Example: 52601 complete transurethral electrosurgical resection of the prostate

Other approaches are reported with 55801-55845

Example: 55801 reports a removal of the prostate gland (prostatectomy) through an incision in the perineum

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Codes in this category are based on approach.

Watch the wording, whether it is a resection or an incision.

Urethra

Excision (53200-53275)

53210 female

53215 male

Repair (53400-53520)

Urethroplasty may be one or two stage

Some codes divided based on male/female

Manipulation (53600-53665)

Stretches of narrowed passage

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Many codes are divided based on whether the patient is male or female.

The dilation codes under the Manipulation category are based on whether it’s initial or subsequent and if the patient is male or female.

Male Genital System Anatomic Subsection

Penis

Testis

Epididymis

Tunica Vaginalis

Scrotum

Vas Deferens

Spermatic Cord

Seminal Vesicles

Prostate

Figure 20.10, A & B

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What is the basis for the subheadings for the Male Genital System codes? (Divided into anatomical subheadings)

What is the basis for the division of the category subheadings? (Subheadings are divided by 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; the other subheadings are used mainly for incision and excision.)

Subsection Format

Format:

Incision

Destruction (method used and if simple or extensive)

Excision

Introduction

Repair

Manipulation

Suture

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Biopsy Codes

Located in subheading to which they refer

Example Biopsy codes in subheadings:

Epididymis (Excision)

Testis (Excision)

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The codes for biopsy are located under the anatomical subheading to which they refer.

Penis

Incision category differs from Integumentary System codes

Penis Incision codes for deeper structures

Example: erectile tissue

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The Incision category under the Penis subheading differs from the codes in the Integumentary System subsection in that the penis incision codes are used for deep incision—not simply for abscess of the skin.

The Incision category codes are 54000-54015.

Destruction (54050-54065)

Codes divided on

Extent: Simple or extensive

Method of destruction: e.g., chemical, cryosurgery

Extensive destruction can be by any method

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The Destruction subcategory includes codes 54050-54065.

Simple destruction is further divided by method of destruction.

The code for extensive lesion destruction can be used regardless of the method employed.

Excision (54100-54164)

Commonly used codes biopsy and circumcision

Appropriate circumcision code is based on method and age of patient

Biopsy, penis

Simple biopsy 54100 (separate procedure)

Complex biopsy 54105

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The Excision category includes codes for biopsy, excision of plaque (Peyronie disease), removal of foreign bodies, amputations, and circumcision.

Peyronie’s Disease

Curvature of penis

Result of plaque formation

Surgical removal of plaque (54110-54112)

Grafting may be necessary to correct defect

Report with 54111, 54112

If harvesting of graft is through a separate incision, see 20920, as appropriate

Figure 20.12

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There are 2 areas for treatment of Peyronie’s disease: the Excision category and Introduction category.

Circumcision

Divided based on if device was or was not utilized

Clamp: 54150

No clamp: 54160 (neonate), 54161 (non-neonate, less than 28 days)

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Circumcision descriptors now include a code for circumcision using a clamp or other device performed with a regional dorsal penile or ring block.

Circumcision codes are divided by neonate (28 days or less) and older than 28 days.

The clamp that is used for circumcision retracts the foreskin while it is being trimmed.

Excision of the foreskin without clamping is typically sutured after the removal.

Introduction (54200-54250)

Many procedures for corpora cavernosum (spongy body of penis)

Injection procedures for Peyronie’s disease (toughening of the corpora cavernosum)

Tests for erectile dysfunction

54240 and 54250 have a global, professional (-26), and technical component (-TC)

Use of appropriate modifier is important when assigning

If hospital setting, physician uses modifier -26 on procedure code

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The Introduction category includes many procedures involving the corpora cavernosum.

Such procedures include injection procedures for Peyronie disease and treatments for erectile dysfunction.

Injection of steroids help to decrease the pain, deformity, and fibrous tissue size.

Repair (54300-54440)

Many plastic repairs

Some repairs are staged (more than one stage)—Modifier -58

Stage indicated in code description

Repair of wounds involving skin and subcutaneous tissue of external male genitalia:

See Integumentary Section codes 12001-13133

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The repair category includes many plastic repairs.

Some repairs involve more than one stage.

Is the stage of repair incorporated into the code description? (Yes)

Chordee and Hypospadias

Chordee: Ventral curve (downward) of penis

Hypospadias: Congenital abnormality

Urethral meatus (opening) is abnormally placed

Repair codes report repair services for chordee and hypospadias

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There are degrees of hypospadias. The degree depends on the location of the opening whether it is anterior, middle, or posterior.

Hypospadias can lead to chordee.

Testis (1 of 2)

Excision (54500-54535)

Biopsy, excision, orchiectomy

Biopsy: Incisional or percutaneous

Orchiectomy codes reported by:

Simple or radical

Unilateral or bilateral

With or without testicular prosthesis insertion

Approach used

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What does orchiectomy mean? (Removal of the testis)

If the procedure is done bilaterally, modifier -50 would be used, unless the code is specified as bilateral.

Testis (2 of 2)

Exploration (54550, 54560)

Undescended testis (cryptorchidism)

Congenital

Testis or testes did not descend into scrotal sac

Unilateral or bilateral

Often associated with hernia

Repair (54600-54680)

Orchiopexy: Moving and fixation of testis to scrotal sac

Abdominal approach: 54650

Laparoscopic: 54692

Code selection based on approach (inguinal, scrotal, or abdominal)

Check CCI edits for bundled procedures

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Many times the undescended testis is associated with a hernia.

Use modifier -50 to indicate bilateral procedure.

Epididymis

Narrow, coiled tube on top of testis

Connects efferent ducts to vas deferens

I&D abscess or hematoma: 54700

Excision category (54800-54861)

Biopsy

Lesion or spermatocele (cyst)

Repair category (54900, 54901)

Epididymovasostomy

Report operating microscope separately (69990)

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Only 4 categories are in the Epididymis subheading: Incision, Excision, Exploration, and Repair.

Code 54700 is for an abscess or hematoma of the testis, scrotal space, or epididymis.

What is a spermatocele? (Cyst that contains sperm)

Tunica Vaginalis (55000-55060)

Serous sheath of testis

Site of hydrocele (fluid collection) (unilateral or bilateral)

Treatment options, such as aspirate, inject, excise, repair

Repair: Bottle type repair (55060)

Drain

Reposition

Catheter left in place

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Like Epididymis subheading, the Tunica Vaginalis contains only 3 categories: Incision, Excision, and Repair.

All are for treatments of hydrocele.

Scrotum (55100-55180)

Sac that contains testes

Site of lesion, abscess, hematoma

I&D

Scrotoplasty (oscheoplasty)

Traumatic defect

Congenital abnormality

May require grafting

Simple skin flaps included in scrotoplasty

More complex grafts/flaps reported separately

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Scrotum is the sac that contains the testes.

If an incision is performed on a lesion of the skin, refer to the Integumentary System.

Skin flaps may need to be used to repair the defect after a scrotoplasty. If a simple skin flap is performed, this is included in the procedure. More complex grafts are reported separately.

Vas Deferens (55200-55400)

Tube that conducts sperm from testes to ejaculatory duct and urethra

Incision: Vasotomy to collect sperm sample or identify obstruction

Excision: Vasectomy for sterilization procedure is described as either unilateral or bilateral

Do not use modifier -50

Introduction: Dye for radiographic procedure

Repair: Remove obstruction, anastomose ends, semen sampling included

Operating microscope: 69990

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In which category would you find vasectomy codes? (Excision)

A postoperative semen examination is included with code 55250.

Spermatic Cord (55500-55559)

Hydrocele: 55500 with modifier -50 bilateral

Varicocele: Trapped blood causes vessels to swell, for excision:

Scrotal approach: 55530

Abdominal approach: 55535

Laparoscopy: 55550

Excision of varicocele and hernia repair: 55540

Watch: “separate procedure” designation. Only billed if only service performed or if procedure totally unrelated to another procedure performed during the same session

Figure 20.13

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The spermatic cord is a collection of structures that suspend the testes in the scrotum.

The procedures in this subheading are either performed excisionally or laparoscopically.

Seminal Vesicles (55600-55680)

Pair of bands, posterior to bladder

Provide majority of semen fluid

Incision: Vesiculotomy

Simple 55600, complicated 55605

Excision: Vesiculectomy

For removal of tumor, calculus, or other obstruction

55650, any approach

Add -50 for bilateral

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What is a vesiculotomy? (A surgical cutting into the seminal vesicles)

Why is this performed? (To relieve pressure due to inflammation)

Prostate (55700-55899)

BPH, Benign Prostatic Hyperplasia

Enlargement of the prostate

Treatment options:

Urethral stent keeps urethra open at level of prostate

52282, permanent

53855, temporary

TUMT (53850) microwave heat

TUNA (53852) radiofrequency

Each code description lists approach and bundled procedures, if appropriate

Slide ‹#›

What are some of the symptoms of BPH? (Urinary frequency, urgency, nocturia, decreases in force of urine stream, and feeling bladder not fully emptied)

Symptoms of BPH are caused by excess prostate tissue pressing against the urethra and bladder.

Incision (55700-55725)

Prostate Biopsy

Needle or punch, 55700

Needle, transperineal, stereotactic, 55706

Incisional, 55705

When fine needle aspiration biopsy performed refer to 10004-10021

Prostatotomy (55720 simple, 55725 complicated)

Drain abscess

Either via perineum or through rectum

Complicated = documented complexity, such as excess bleeding

Slide ‹#›

Do not report a needle or punch biopsy with an incisional biopsy during the same operative session.

BPH or Neoplasm Surgical Options

TURP (52601, 52630) gold-standard

Through urethra, electrical loop removes obstruction

TUIP (52450)

Incisions relieve pressure, no tissue removed

Slide ‹#›

What does TURP stand for? (Transurethral resection of the prostate)

What does TUIP stand for? (Transurethral incision of the prostate)

Prostatectomy (1 of 5)

Two types of codes:

Coagulation (52647)

Vaporization (52648)

Vaporization may be with or without resection

Slide ‹#›

Use of a laser to accomplish the prostatectomy is either considered coagulation or vaporization.

Prostatectomy (2 of 5)

Coagulation, laser (52647)

Contact or noncontact

Contact: Laser comes in contact with prostate tissue

Noncontact: Laser does not come in contact with prostate tissue

TULIP (noncontact) no direct view by surgeon

VLAP (noncontact) direct view by surgeon

ILCP (contact) no direct view by surgeon

Slide ‹#›

Coagulation causes the tissue to die and slough off.

During TULIP there is no direct visualization of the prostate, and the penetration isn’t as deep as other methods.

VLAP is done under direct visualization by the surgeon.

Prostatectomy (3 of 5)

Laser vaporization (52648)

TUVP or TVP (contact) electrical current vaporizes tissue by means of a ball that is rolled over tissue

Laser vaporization with/without resection (52648)

HoLEP or THLR (contact) laser resects tissue with holmium laser fiber

Slide ‹#›

Vaporization is done through electrical currents.

Use of the HoLEP procedure causes less intraoperative bleeding than with a TURP.

Prostatectomy (4 of 5)

55801-55845 open surgical procedures

First based on approach

Perineal: Space between rectum and scrotum

Suprapubic: Above the pubic bone

Retropubic: Posterior to the pubic bone

Second based on extent

Subtotal or radical

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What does prostatectomy mean? (Removal of the prostate)

Subtotal removal means anything less than total.

Radical removal means total removal of the prostate.

Prostatectomy (5 of 5)

LRP (55866)

Laparoscopic = minimally invasive

RAP (no CPT code)

Use with 55866 with modifier -22

www.davinciprostatectomy.com/da-vinci-prostatectomy/

Slide ‹#›

A substitute for an open prostatectomy may be an LRP (Laparoscopic Retropubic Prostatectomy).

RAP (Robotic Assisted Prostatectomy) is new and is used at times with LRP. It assists in the performance of some surgical tasks.

Brachytherapy (55860-55865)

Methods

High dose, temporarymethod

Low dose, permanentimplants (seeds)

Placement

Transperineal (55875)

Open exposure (55862)

Radioelements reported with 77778, 77799

Brachytherapy for prostate cancer

Modified from Wein AJ, editor: Campbell-Walsh Urology, ed 9, Philadelphia, 2007, Saunders.

Figure 20.14

Slide ‹#›

This is typically performed in conjunction with a urologist and a radiation oncologist.

What is the difference between the high dose and low dose methods? (High dose is temporary and performed by placement of small catheters into the prostate, and radiation treatment is delivered internally. Low dose is when permanent seeds are placed through a needle into the area between the scrotum and anus.)

ConclusionCHAPTER 20

URINARY AND MALE GENITAL SYSTEMS

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