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Jennifer Posted Wed 16th of May, 2012 18:46:08 PM

Our doc was called in to consult for a bladder laceration during a vaginal hysterectomy. He repaired the laceration - no mention of an abdominal incision .. it looks like 51860 and 51865 are for open procedures only- How would I code this ? The laceration was viewed and I guess repaired via the vaginal incision .
Thanks !

SuperCoder Answered Wed 16th of May, 2012 19:18:47 PM

Repair of incidental bladder cystotomy 51860 (Cystorrhaphy, suture of bladder wound, injury or rupture; simple) or 51865 ( complicated). The exploratory laparotomy is always bundled into a more extensive procedure, so you would not report it separately.

There are two potential methods to code the bladder repair, depending on the degree of consultation required of the urologist.

If the gynecologist performing the hysterectomy and cystotomy informs your doctor of the laceration of the bladder that must be closed, you cannot bill for a consultation. Therefore, you should code 51860 (Cystorrhaphy, suture of bladder wound, injury or rupture; simple) for a simple procedure, or 51865 (… complicated) if the procedure can be considered complicated.

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