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Opinion about CPT code for surgery

Wendy Posted Mon 13th of April, 2015 09:24:51 AM

My urologist was called into the operating room by a GYN doctor who accidently put 2 sutures into her patient's bladder while performing her surgery. I would like your opinion if 52310 is the code I should use. Documentation states: "The cystoscope was placed into the bladder. There were 2 sutures noted in the base of the bladder cephalad to the trigone. They were puckering the wall. Using the meatotomy scissors, I was able to cut both sutures and they were removed using the grasping forceps." Thank you!

SuperCoder Answered Tue 14th of April, 2015 02:36:46 AM

As per NCCI, cystourethroscopy performed near the termination of an intra-abdominal, intra-pelvic, or retroperitoneal surgical procedure to assure that there was no intraoperative injury to the ureters or urinary bladder and that they are functioning properly is not separately reportable with the surgical procedure. Therefore, you cannot bill for the cystourethroscopy.

Wendy Posted Tue 14th of April, 2015 08:47:59 AM

If you look at the documentation, we did not do the cysto to see if there was an injury to the bladder or ureter. Another physician from another office accidently put sutures into the patient's bladder while she was closing the wound from her surgery. We were called into the OR to remove the sutures at the other physician's request. That other physician's office will be billing the primary surgery as we were not involved in that. Is 52310 appropriate to use for the removal of sutures inadvertantly sewed into the bladder by a physician from another office?

SuperCoder Answered Wed 15th of April, 2015 03:44:48 AM

Yes you can use CPT code 52310 for the removal of suture when performed through cystourethroscopy. Suture will be considered foreign body in this scenario.

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