Nicole Posted Fri 04th of December, 2015 13:48:36 PM
Doctor did the following: Cystoscope sheath was inserted in the urethra. A wire was passed through this into the bladder. The holmium laser was used to open up the stricture and evaporate it. He then saw the tip of the suprapubic tube and this was removed.
Would the CPT code 52276 be appropriate for this? Also, would the removal of the suprapubic tube be inclusive or is that billable as well (using what CPT Code)?
SuperCoder Answered Mon 07th of December, 2015 05:01:45 AM
As holmium laser was used in this procedure, most appropriate CPT is 52648 Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed).
There is no need to code for removal of the suprapubic tube as it is inclusive in this procedure.
SuperCoder Answered Mon 07th of December, 2015 05:21:14 AM
As you have not documented the diagnosis in your query, I was assuming it as prostate disorder first, but if diagnosis is bladder neck contracture which is in fact a urethral stricture at the vesicourethral junction, you should report 52276 (Cystourethroscopy with direct vision internal urethrotomy). Code 52276 represents a straightforward cutting of the stricture.
Nicole Posted Wed 09th of December, 2015 13:26:37 PM
Yes, the diagnosis is: Urethral Stricture.
Therefore the CPT code 52276 would be the appropriate CPT code, correct?
SuperCoder Answered Thu 10th of December, 2015 00:39:32 AM
Correct, CPT code 52276 would be the appropriate CPT code for diagnosis Urethral Stricture.