CHAPTER 24 URINARY AND MALE GENITAL SYSTEMS Copyright

CHAPTER 24 URINARY AND MALE GENITAL SYSTEMS Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 1

Urinary System • Anatomic divisions – Kidney – Ureters – Bladder – Urethra • Procedures on prostate in either Urinary or Male Genital System (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Figure: 24. 1 Slide 2

Urinary System (…Cont’d) • Further divided by procedure – Incision – Excision Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 3

Kidney (50010 -_____) 50593 • Endoscopy codes for procedures done through – Previously established stoma _____ – Incision • Most cystoscopy procedures have zero global days • A cystoscopy is a visual examination of urinary bladder by means of cystoscope Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Figure: 24. 6 Slide 4

Incision (50010 -50135) • Caution: retroperitoneal area – Kidney located in ______ – Each has codes for procedures • Renal exploration – Kidney diagnostic procedure (50010), no further procedures performed – Retroperitoneal area diagnostic procedure (49010) • Renal abscess – Kidney abscess (50020) – If radiological supervision & interpretation were performed see 75989 – Retroperitoneal abscess (49060) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 5

Procedures • Nephrostomy (50040): Insertion of catheter into kidney with one end in kidney and one end outside body inside of • Nephrotomy (50045): Exploration of _____ kidney – No definitive procedure – Verify all CCI code edits to prevent unbundling • Nephrolithotomy (50060 -50075): Removal of calculus _______ (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 6

Procedures (…Cont’d) • ESWL: Use of shock waves to fragment calculus • Percutaneous lithotripsy: Insertion of probe to pulverize calculus Figure: 24. 3 – Basket attached to probe and pulverized calculus removed • Percutaneous ______________ nephrostolithotomy (PCNL) or pyelostolithotomy – Removal of kidney calculus Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 7

Excision (50200 -50290) • Nephrectomy: Partial or ____ total (radical) excision of kidney (50220 -50240) – Radical: Removal of fascia, fatty tissue, regional lymph node, adrenal gland • Nephrectomy medical record documentation should indicate if procedure was partial or total, laparoscopic, or open, and if any structures were removed • Code 50225 describes a complicated nephrectomy because of previous surgery on same kidney • Ablation Cryosurgery 50250 – _____, Laparoscope 50542 – ______, – Percutaneous, 50593 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 8

Renal Transplant (50300 -50380) • Backbench work organ – Retrieval of _____ • Deceased (50300) • Living (50320, open; 50547, laparoscopy) – Preparation _____ of organ • Deceased (50323) • Living (50325) – Transplantation • Without _______ nephrectomy, 50360 • With ____ nephrectomy, 50365 -50 for bilateral procedure • Add ___ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 9

Introduction (50382 -50398) • Aspirations • Catheters and injections for radiography • Insertion of guidewires • Tube changes • Usually reported with radiology component Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 10

Repair (50400 -50540) • Pyeloplasty ureteropelvic junction (UPJ) – Repair of _________ Simple 50400 – ______ 50405 – Complicated _____ • Closure of fistula (abnormal opening) 50526 – 50520 -_____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 11

Laparoscopy (50541 -50549) • Ablation of renal – Cyst ____ (50541) – Lesion (_____) 50542 – _____ Cryoablation (50250) – Percutaneous (50593) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 12

Endoscopy (50551 -50580) • Renal endoscopy codes divided by – Established connection between kidney and body exterior (50551 -50562) – Nephrotomy or pyelotomy (50570 -50580) purpose • Further divided based on _______ – Biopsy – Removal of foreign body/calculus Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 13

Ureter • Divided based on type of procedure – Incision – Excision • Laparoscopy codes describe surgical procedures unilateral • Codes may be bilateral or ____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 14

Incision (50600 -50630) • Report open procedures – Explore or ____ drain (50600) – Insert indwelling ____ stent (50605) – Remove _______ calculus (50610 -50630) upper third, middle • Based on location of _____ third, or lower ____ third Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 15

Excision and Introduction (50650 -50690) • Excision – Ureterectomy (50650, 50660 _____) • Bladder cuff excision or total excision • Introduction manometric (measures – Reports injections, _____ pressure) studies, change of stents/tubes Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 16

Laparoscopy and Endoscopy (5094550980) • Laparoscopic placement of ureteral stent (50947, 50948 _____) • Endoscopy codes (50951 -50980) for procedure through ________ established stoma Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 17

Bladder • Many bundled codes – Example: Urethral dilation is included with insertion of cystoscope • Read all descriptions carefully for site, technique, and reason for procedure Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Figure: 24. 8 Slide 18

Incision and Excision • Incision (51020 -51080) Cystotomy (51020 -51045) for lesion – _____ destruction, insertion of radioactive material, fulguration (use of electrical current) – Suprapubic _____ catheter placement, 51102 • Excision (51500 -51597) – Cystotomies & cystectomies (51520 -51596) • Codes divided based on _____ extent of procedure Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 19

Introduction (51600 -51720) • Injection procedures (51600 -51610) for urethrocystography – Radiographic S&I reported separately • Instillation of anticarcinogenic agent via a _______ catheter for bladder cancer – Retention _______ time included Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 20

Urodynamics (51725 -51798) • Procedures relate to motion and flow of urine (motor & sensory function) • Used to diagnose urine flow obstructions necessary instruments, • Bundled: All usual, _____ technical assistance equipment, supplies, and _______ • Always code urodynamic code in addition to all other cysto codes if both are performed -51 is reported for multiple procedures • Modifier ___ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 21

Repair and Laparoscopy • Repair (_____-51980) 51800 – Cystoplasty – Cystourethroplasty – Vesicourethropexy/uretropexy (urinary incontinence) • Laparoscopy (51990 -_____) 51999 – Stress _____ incontinence procedures Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 22

Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy • 52000 -52010 • Many combination codes • Notes before 52000 indicate that included are: – Meatotomy calibration – Urethral _____ – Urethral dilation – Urethroscopy – Cystoscopy – Ureteral catheterization, etc. (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 23

Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy (…Cont’d) • 52000 is assigned for IVP, if appropriate • 52005 is assigned for retrograde pyelogram • When coding cystourethroscopies with dilation ask following questions: 1. Is patient male or female? 2. Is this an initial or subsequent procedure? 3. Was general or spinal anesthesia used? • Additional time/effort of second procedure • Modifier -22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 24

Transurethral Surgery (52204 -52355) • Urethra/bladder, 52204 -52318 – TURBT (52234 -52240) • Excision or fulguration of bladder tumor • Ureter/pelvis, 52320 -52355 – Includes insertion and removal of temporary stents Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 25

Vesical Neck and Prostate (52400 -52700) transurethral • Contains codes for ______ resection of the prostate (TURP) __________ – Example: 52601 complete transurethral electrosurgical resection of the prostate • Other approaches are reported with 55801 -55845 – Example: 55801 reports a removal of the prostate gland (prostatectomy) through an perineum incision in the ____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 26

Urethra • Excision (53200 -53275) – _____ 53210 female – 53215 _____ male • Repair (53400 -53520) two stage – Urethroplasty may be one or ___ – Some codes divided based on male/female • Manipulation (53600 -53665) – Stretches ____ of narrowed passage Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 27

Male Genital System Anatomic Subsection • Penis • Testis • Epididymis • Tunica Vaginalis • Scrotum • Vas Deferens • Spermatic Cord • Seminal Vesicles • Prostate Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Figure: 24. 10, A & B Slide 28

Subsection Format • Format: – Incision – Destruction (method used & if simple or extensive) – Excision – Introduction – Repair – Manipulation – Suture Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 29

Biopsy Codes • Located in subheading to which refer – Example Biopsy codes in subheadings: • Epididymis (Excision) • Testis (Excision) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 30

Penis • Incision category differs from Integumentary System codes • Penis Incision codes for ______ deeper structures – Example: erectile tissue Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 31

Destruction (54050 -54065) • Codes divided on – Extent: Simple or extensive Method of _____: destruction e. g. , chemical, – ______ cryosurgery • Extensive destruction can be by any method Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 32

Excision (54100 -54164) • Commonly used codes biopsy and _____ circumcision – Appropriate circumcision code is based on method and age of patient • Biopsy, penis – ______ Simple biopsy 54100 (separate procedure) – Complex _______ biopsy 54105 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 33

Peyronie Disease • Curvature of penis plaque formation • Result of ______ • Surgical removal of plaque 54112 (54110 -_____) • Grafting may be necessary to correct defect – Report with 54111, 54112 _____ – If harvesting of graft is through a separate incision, see 20920 & 20926, as appropriate Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Figure: 24. 12 Slide 34

Circumcision • Divided based on if device _____ was or was not utilized Clamp 54150 • _____: • No _______ clamp: 54160 (neonate), 54161 (non-neonate, less than 28 days) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 35

Introduction (54200 -54250) • Many procedures for corpora cavernosum (spongy body of penis) – Injection procedures for Peyronie disease (toughening of the corpora cavernosum) – Tests for erectile dysfunction • 54240 and 54250 have a global, professional (-26), and technical component (-TC) • Use of appropriate modifier is important when assigning • If hospital setting, physician uses modifier -26 on procedure code Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 36

Repair (54300 -54440) • Many plastic repairs • Some repairs are staged (more than one stage)—Modifier -58 – Stage indicated in code description • Repair of wounds involving skin and subcutaneous tissue of external male genitalia: – See Integumentary Section codes 1200113133 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 37

Chordee and Hypospadias • Chordee _______: Ventral curve (downward) of penis • Hypospadias ______: Congenital abnormality – Urethral meatus (opening) is abnormally placed • Repair codes report repair services for chordee and hypospadias Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 38

Testis • Excision (54500 -54535) – Biopsy, excision, orchiectomy • Biopsy: Incisional or percutaneous • Orchiectomy codes reported by: – Simple or radical – Unilateral or bilateral – With or without testicular prosthesis insertion – Approach used (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 39

Testis (…Cont’d) • Exploration (54550, 54560) • Undescended testis (cryptorchidism) – – Congenital Testis or testes did not descend into scrotal sac Unilateral or bilateral hernia Often associated with _____ • Repair (54600 -54680) Orchiopexy : Moving and fixation of testis to scrotal sac – _____ Abdominal approach: 54650 • _____ 54692 • Laparoscopic: ______ • Code selection based on approach (inguinal, scrotal, or abdominal) • Check CCI edits for bundled procedures Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 40

Epididymis • Narrow, coiled tube on top of testis • Connects efferent ducts to vas deferens • I&D abscess or hematoma: 54700 _____ • Excision category (54800 -54861) – Biopsy – Lesion or spermatocele (cyst) • Repair category (54900, 54901) – Epididymovasostomy – Report operating microscope separately (69990) ______ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 41

Tunica Vaginalis (55000 -55060) • Serous sheath of testis hydrocele (fluid collection) (unilateral or • Site of ____ bilateral) – Treatment options, such as aspirate, inject, excise, repair Bottle type repair (55060) – Repair: _____ • Drain • Reposition • Catheter left in place Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 42

Scrotum (55100 -55180) • Sac that contains testes • Site of lesion, abscess, hematoma – I&D • Scrotoplasty (oscheoplasty) – Traumatic defect – Congenital abnormality – May require grafting Simple skin flaps included scrotoplasty • ______ • More complex grafts/flaps reported separately _____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 43

Vas Deferens (55200 -55450) • Tube that conducts sperm from testes to ejaculatory duct urethra and ______ • Incision: Vasotomy to collect sperm sample or identify obstruction • Excision: Vasectomy for sterilization procedure is described as either unilateral or bilateral -50 – Do not use modifier ___ radiographic procedure • Introduction: Dye for _____ semen • Repair: Remove obstruction, anastomose ends, ______ sampling included – Operating microscope: 69990 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 44

Spermatic Cord (55500 -55559) • Hydrocele: 55500 with -50 ___ bilateral • Varicocele: Trapped blood causes vessels to swell, for excision: Scrotal ______ approach: 55530 Abdominal approach: 55535 _____ Laparoscopy: 55550 Excision of varicocele and hernia repair: 55540 – Watch: “separate procedure” designation. Only billed if only service performed or if procedure totally unrelated to another procedure performed during the same session – – Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Figure: 24. 13 Slide 45

Seminal Vesicles (55600 -55680) • Pair of bands, posterior to bladder • Provide majority of semen fluid • Incision: Vesiculotomy complicated 55605 – Simple 55600, _____ • Excision: Vesiculectomy – For removal of tumor, calculus, or other obstruction – 55650, any approach – Add -50 for bilateral Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 46

Prostate (55700 -55899) Benign Prostatic Hyperplasia • BPH, ____________ – Enlargement of the prostate • Treatment options: stent keeps urethra open at level of prostate – Urethral ____ • 52282, permanent • 53855, temporary microwave heat – TUMT (53850) _____ 53852 radiofrequency – TUNA (_____) • Each code description lists approach and bundled procedures, if appropriate Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 47

Incision (55700 -55725) • Prostate Biopsy punch 55700 – Needle or _____, – Needle, transperineal, stereotactic, 55706 – Incisional, 55705 • When fine needle biopsy/aspiration performed refer to 10021 & 10022 • Prostatotomy (_____ 55720 simple, 55725 _____) complicated – Drain abscess – Either via perineum or through rectum – Complicated = documented complexity, such as excess bleeding Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 48

BPH or Neoplasm Surgical Options • TURP _____ (52601, 52630) gold-standard – Through urethra, electrical loop removes obstruction • TUIP ____ (52450) – Incisions relieve pressure, no tissue removed Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 49

Prostatectomy • Two types of codes: – Coagulation _____ (52647) – Vaporization _____ (52648) • Vaporization may be with or without resection (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 50

Prostatectomy (…Cont’d) • • Coagulation, laser (52647) Contact or Non-contact Contact: Laser comes in contact with prostate tissue Non-Contact: Laser does not come in contact with prostate tissue view by surgeon • TULIP (non-contact) no direct ____ • VLAP (non-contact) direct view by surgeon • ILCP (contact) no direct view by surgeon (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 51

Prostatectomy (…Cont’d) • Laser vaporization (52648) – TUVP or TVP (contact) electrical current vaporizes tissue by means of a ball that is rolled over tissue • Laser vaporization with/without resection (52648) – Ho. LEP or THLR (contact) laser resects tissue with holmium laser fiber (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 52

Prostatectomy (…Cont’d) • 55801 -55845 open surgical procedures • First based on approach – Perineal _______: Space between rectum and scrotum – Suprapubic _____: Above the pubic bone – Retropubic _____: Posterior to the pubic bone extent • Second based on _____ – Subtotal or radical (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 53

Prostatectomy (…Cont’d) • LRP (55866) • Laparoscopic = minimally invasive • RAP (no CPT code) 55866 with -22 – Use with ______ – www. davinciprostatectomy. com/video. html Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 54

Brachytherapy (55860 -55865) Brachytherapy for prostate cancer • Methods – High dose, temporary ____ method permanent – Low dose, _____ implants (seeds) • Placement – Transperineal (55875) – Open exposure (55862) Figure: 24. 14 Modified from Wein AJ, editor: Campbell-Walsh Urology, ed 9, Philadelphia, 2007, Saunders. • Radioelements reported with 77776 _____-77778 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 55

Conclusion CHAPTER 24 URINARY AND MALE GENITAL SYSTEMS Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 56