Bill Posted Wed 01st of October, 2014 08:51:40 AM
I code for an ASC and the urologist states in his OP report that he did a "Scrotal exploration, retrograde urethrogram and cystogram" In the body of the report he states "once the patient was under anesthesia, the area was explored, as he was difficult to examine in the office secondary to discomfort. There was a dimple at the shaft of the ventral side of the penis suggestive of an old traumatic hypospadias versus a fistula formation versus a communication with only the scrotum. A retrograde urethrogram was performed using fluoro and there was a complete obstruction of the urethra with no evidence of drainage from the fistula or dimpled site. At this point, his suprapubic tube was changed out for a new one. A cystogram was performed showing no evidence of leakage into this area. Therefore, due to the fact that there was no communication with the fistulous tract and the wound did not appear infected, urinary diversion with a suprapubic tube and continued observation would be our first course of management"
My question is, since a scrotal exploration wasn't really done, should I still code this with "55110" and modifier 74? Also, would I code "51705" for exchange suprapubic tube?
Bill Posted Mon 06th of October, 2014 10:45:00 AM
I was wondering if you might have an answer for me on this? Thank you
SuperCoder Answered Mon 06th of October, 2014 16:47:39 PM
Thank you for your question.
55110 with modifier 74 would be appropriate. The documentation states that the procedure was started and a portion of the procedure was completed. The 51705 (In this procedure, the provider performs a simple removal of a tube that he previously places into a patient’s bladder and replaces it with a new tube through the same incision.) would also be appropriate to bill with the procedure performed, using a modifier 51 to indicate multiple procedures.