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

2. Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Urinary System Anatomic divisions –Kidney –Ureters –Bladder –Urethra Procedures on prostate in either Urinary or Male Genital System (Cont’d…) Figure: 24.1

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

4. Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Kidney (50010-_____) Endoscopy codes for procedures done through –Previously established _____ –Incision Most cystoscopy procedures have zero global days A cystoscopy is a visual examination of urinary bladder by means of cystoscope 50593 stoma Figure: 24.6

5. Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Incision (50010-50135) Caution: –Kidney located in ____________ area –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) retroperitoneal

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

7. Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Procedures (…Cont’d) ESWL : Use of shock waves to fragment calculus Percutaneous lithotripsy: Insertion of probe to pulverize calculus –Basket attached to probe and pulverized calculus removed ___________________________ (PCNL) or pyelostolithotomy –Removal of kidney calculus Percutaneous nephrostolithotomy Figure: 24.3

8. Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Excision (50200-50290) Nephrectomy: Partial or ____ (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 –__________, 50250 –___________, 50542 –Percutaneous, 50593 total Cryosurgery Laparoscope

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

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

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

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

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

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

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

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

17. Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Laparoscopy and Endoscopy (50945- 50980) Laparoscopic placement of ureteral stent (50947, _____) Endoscopy codes (50951-50980) for procedure through _______________ 50948 established stoma

18. Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Bladder Many bundled codes –Example: Urethral dilation is included with insertion of cystoscope Read all descriptions carefully for site, technique, and reason for procedure Figure: 24.8

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

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

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

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

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

24. Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy 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 (…Cont’d)

25. Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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

26. Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Vesical Neck and Prostate (52400-52700) Contains codes for ___________ ____________________ (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 incision in the ________ transurethral resection of the prostate perineum

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

28. Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Male Genital System Anatomic Subsection Penis Testis Epididymis Tunica Vaginalis Scrotum Vas Deferens Spermatic Cord Seminal Vesicles Prostate Figure: 24.10, A & B

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

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

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

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

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

34. Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Peyronie Disease Curvature of penis Result of ______ formation Surgical removal of plaque (54110-_____) Grafting may be necessary to correct defect –Report with 54111, _____ –If harvesting of graft is through a separate incision, see 20920 & 20926, as appropriate plaque 54112 Figure: 24.12

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

36. Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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

37. Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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 12001- 13133

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

39. Slide 39 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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…)

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

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

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

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

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

45. Slide 45 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Spermatic Cord (55500-55559) Hydrocele: 55500 with ___ bilateral Varicocele: Trapped blood causes vessels to swell, for excision: –______ approach: 55530 –_________ 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 -50 Scrotal Abdominal Figure: 24.13

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

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

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

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

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

51. Slide 51 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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 TULIP (non-contact) no direct ____ by surgeon VLAP (non-contact) direct view by surgeon ILCP (contact) no direct view by surgeon (Cont’d…) view

52. Slide 52 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 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) –HoLEP or THLR (contact) laser resects tissue with holmium laser fiber (Cont’d…)

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

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

55. Slide 55 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Brachytherapy (55860-55865) Methods –High dose, ________ method –Low dose, _________ implants (seeds) Placement –Transperineal (55875) –Open exposure (55862) Radioelements reported with _____-77778 Brachytherapy for prostate cancer Modified from Wein AJ, editor: Campbell-Walsh Urology, ed 9, Philadelphia, 2007, Saunders. temporary permanent 77776 Figure: 24.14

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