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Cherie Posted Tue 30th of September, 2014 10:39:35 AM

Please see below: Turp? I had to push the scope through the bulbous urethral stricture. There was bleeding from the bladder neck after passage of the scope. I then dilated the urethra up to 30 French with Vanburen urethral sounds and placed the bipolar resectoscope sheath. I used the bipolar resectoscope and Foroblique lens to resect this tissue arising from the floor of the bladder and circumferentially around the bladder neck. Cautery was used for hemostasis and this specimen was removed w/ an Ellik evacuator and sent to pathology .

Cherie Posted Mon 06th of October, 2014 11:29:49 AM

Is there someone checking on this?

SuperCoder Answered Tue 07th of October, 2014 06:51:27 AM

You may use code 52500, Transurethral resection of bladder neck; separate procedure.

Code 52500’s descriptor indicates it is a separate procedure, meaning that provider cannot report this code separately with a related procedure when performed in an anatomically related region through the same skin incision. If the provider performs the 52500 procedure with an unrelated procedure, you may need to append modifier 59, Distinct Procedural Service to 52500.

Thanks !!

SuperCoder Answered Tue 07th of October, 2014 15:03:10 PM

Hi there.

I asked the consulting editor of Urology Coding Alert to take a look at your question and he offers this advice:

"The operative report is incomplete, but it appears the urologist just resected the bladder neck, CPT code 52500, if this was a primary contracture of the bladder neck secondary to BPH largely forming at the bladder neck and arising from the floor of the prostate. A bladder neck contracture secondary to previous surgery such as a previous TURP or a radical prostatectomy, should be coded with CPT code 52640, transurethral resection of postoperative bladder neck contracture. The urethral dilation is bundled into both of these two codes and not separately billable."

I hope this helps.


Leesa A. Israel, BA, CPC, CUC, CPPM, CMBS
Managing Editor, The Coding Institute, including Urology Coding Alert
Audit Manager - Training, TCI Consulting & Revenue Cycle Solutions

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