Medical Billing and Coding
Chapter 19 – Urinary System and Male Genital Systems
http://kidshealth.org/kid/grow/index.html
Male Genital System (54000-55899)
 Divided into anatomic headings
 Then divided according to procedure
Penis




Incisions and Destructions (54000 – 54015)
Incision and Drainage – 54015
Note: Incisions are for deep incisions
Destruction – 54050 – 54065
o Simple or Extensive – based on method used
 Excision – 54100 – 54164
o Biopsy – 54100, 54105 – can bill if it’s the only procedure performed during the
operative session, if performed with another procedure, cannot bill, considered bundled
into the main procedure
o Peyronie Disease (54110 – 54112) – surgical correction involves removal of the penile
plaque
 54110 – no grafting
 54111, 54112 – requires grafting
o Penile Amputation – 54120, 54125
o Also remove Lymph Notes – 54130, 54135
o If performed as a separate procedure – 38760 – 38765
o Circumcision (54150 – 54161)
o Newborn – 54150
o Neonate (baby 28 days of age or less) – 54160
o Baby older than 28 days of age – 54161
The pediatric physician takes this newborn male to the nursery to perform a clamp circumcision.
A.
B.
C.
D.
54160, V50.2 (Circumcision in absence of medical indication)
54150, V50.21
54160, V50.21 (there is no such diagnosis)
54150, V50.2
54150 – Circumcision using clamp or other device with regional dorsal penile or ring block
54160 – Circumcision surgical excision other than clamp, device, or dorsal slit: neonate (28 days of
age or less)
 Introduction – 54200 – 54250
o Report various injection procedures, irrigation, plethysmography and other tests
o Priapism (54220) – state of prolonged erection
 Repair – 54300 – 54440
o Often state the condition for which the procedure is being performed
o Chordee – condition in which the penis has a ventral (downward) curve and is a
congenital deformity
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o Hypospadias – congenital abnormality in the underside of the shaft
 Degrees of hypospadias
 Location – anterior, middle, posterior
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Medical Billing and Coding
Chapter 19
This 1-year old boy has a midshaft hypospadias with a very mild degree of chordee. He also has a
persistent right hydrocele. The surgeon brought the boy to surgery to perform a right hydrocele
repair and one-stage repair of hypospadias with preputial onlay flap.
A.
B.
C.
D.
54322, 55040, 752.61, 752.63 (congenital chordee)
54322, 55041-51, 752.61 (Hypospadias (male), 752.63, 603.9 (hydrocele)
54324, 55060-51, 752.61, 752.63, 603.9
54324, 55060, 752.63, 603.9
54322 – 1-stage distal hypospadias repair (with or without chordee or circumcision); with simple
meatal advancement (eg. Magpi, V-flap)
54324 - 1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty
by local skin flaps (eg, flip-flap, prepucial flap) (flap is a type of graft)
55040 – Excision of hydrocele; unilateral
55060 – Repair of tunica vaginalis hydrocele (Bottle type) - A hydrocele is a fluid collection within the
tunica vaginalis of the scrotum or along the spermatic cord.
55041 – Excision of hydrocele: bilateral
In the United States a study reported that hypospadias was the most common congenital anomaly among whites.
The incidence has been rising during the 1970s and 1980s
http://hypospadias-surgery.com/engl_faq_1.html
 Sections 54400 – 54417 – for the insertion, repair, or removal of various types of penile
prosthesis, and further divided based on the type of service and often on the circumstances of
the service
o Note: Impotence
 54400 – no inflatable prosthesis
 54401 – Inflatable prosthesis
 54406 – removal of inflatable implant
 54115 – removal of a no inflatable implant
Testis
 Excision 54500 – 54535
o Percutaneous Biopsy – 54500
o Incisional Biopsy – 54505
 Note: (use modifier -50 with 54505 if biopsy performed)
 Extraparenchymal – unrelated to the essential elements of an organ – removed
is 54512
 Orchiectomy – removal of the testis - 54520 – 54535
- Watch for codes indicating unilateral or bilateral
- 54530 does not require modifier -50
 Exploration 54550, 54560
o Exploration codes – add modifier 50
 Repair/Laparoscopy 54600 - 54699
o Undescended Testis – 54550, 54560
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o Orchiopexy – 54640 or 54650 or 54692 – dependent upon approach
Medical Billing and Coding
Chapter 19
Epididymis – 54700
 Incision and drainage of each or all of the areas
o For debridement, go to the 11000 codes
 Excision – 54800 – 54861
 Exploration - 54865
 Repair for Epididymovasotomy – 54900 or 54901
o Watch for modifier usage for unilateral and bilateral RT,LT or -50)
Tunica Vaginalis – 55000, 55040, 55041
 Incision 55000
o If hernia repair also – 49495 – 49501
 Excision 55040, 55041
 Repair (Bottle Type Repair) – 55060
Scrotum – 55100 - 55180
 Incision 55100 - 55120
o If abscess – 54700
 Excision 55150
o If just a lesion being removed go to the 11000 section of CPT
 Repair –55175, 55180
o Scrotoplasty 55175
o Oscheoplasty – repair of a congenital abnormality or traumatic defect of the scrotum
Vas Deferens – 55200 – 55450
 Incision 55200
 Excision 55250
 Introduction 55300
o Radiological supervision and interpretation, use 74440
o When combined with biopsy of testis, see 54505, use modifier 51
o Note: no modifier -50 needed
 Repair 55400
o Vasovaostomy, vasovasorrphaphy
 If bilateral, use modifier -50
Vas Deferens – 55200 – 55450
 Suture 55450
Spermatic Cord 55500 - 55599
 Excision 55500 - 55540
o 55500 – Modifier -50
o 55530 – Scrotal Approach
o 55535 – Abdominal Approach
o 55540 – Varocele Excision and a hernia repair
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 Laparoscopy 55550, 55559
Medical Billing and Coding
Chapter 19
Seminal Vesicles 55600 - 55680
 Incision – 55600, 55605
o Uses modifier -50
 Excision – Vesiculectomy, any approach – 55650, 55680
o Surgery for Mullerian Ducts – 55680
Note: The below listed procedures are coded from the Urinary System and/or the Male Genital
System
Prosthetic Implants – 52282 (pg 261 CPT)
Abbreviations – See index of CPT book and your textbook (pg 591-592 SBS)
 TUMT (Transurethral Microwave Health Treatment) -53850 (pg 265 CPT)
 TUNA (Transurethral Needle Ablation) – 53852 (pg 265 CPT)
 TURP (Transurethral Resection of the Prostate - 52601, 52630 ( pg 262-263 CPT)
o Note: If stated use modifier -58 on 52601
Video for a TURP
http://www.youtube.com/watch?v=ADvoJphHHIc&feature=fvw
 TUIP (Transurethral Incision of the Prostate) 52450 (pg 262 CPT)
 TULIP ( Transurethral Ultrasound-Guided Laser Induced Prostatectomy) 52647 (pg 263 CPT)
o VLAP (Visual Laser of the Prostate)
o ILCP (Interstitial Laser Coagulation of Prostate)
 TUVP or TVP (Transurethral Vaporization of the Prostate) – 52648 (pg 263 CPT)
o THLR (Transurethral Holmium Laser Resection) – 52648 (pg 263 CPT)
o HoLEP (Holmium Laser Enucleation of the Prostate) 52648 (pg 263 CPT)
Prostatectomy – 55801 – 55845
 Perineal
 Suprapubic
 Retropublic
Lymph Node Biopsy – watch the approach and if unilateral or bilateral
o Perineal 55812
o Retropubic 55842
o Perineal 55815
o Retropublic 55845
o LRP (Laparoscopic Retropubic Prostatectomy) 55866
o RAP (Robotic Assisted Prostatectomy )
o Can view procedure at http://www.davinciprostatectomy.com/video.html
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 TRU – Transrectal Ultrasound – 55970 – 55980
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Medical Billing and Coding
Chapter 19
Prostate 55700 – 55899 – read the notes under procedures before coding
Note: BPH (benign prostate hypertrophy), go to Urinary System and / or Male Genital System
 Incision 55700 – 55725
o Biopsy 57700 – 55706
 Prostatotomy – incision into the prostate 55720 – 55725
 TRU (Transrectal Ultrasound) 76872, 76873
 Excision 55801 – 55865
o Brachytherapy – 55860 – 55865
 If using radioactive elements – 77776 – 77787
 Laparoscopy 55866
 Other Procedures 55870 – 55899
Reproductive System Procedures 55920 – read notes
Intersex Surgery – 55970 and 55980
Urinary System – 50010 – 50135
This section is arranged anatomically – when looking at the procedures, they start from
the Kidney and stop at the Urethra (top to bottom approach)
http://kidshealth.org/kid/htbw/_bfs_USmoviesource.html
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Medical Billing and Coding
Chapter 19
http://kidshealth.org/kid/htbw/index.html
The urinary tract is a pathway that includes the:
kidneys: two bean-shaped organs that filter waste from the blood and produce urine
ureters: two thin tubes that take pee from the kidney to the bladder
bladder: a sac that holds pee until it's time to go to the bathroom
urethra: the tube that carries urine from the bladder out of the body when you pee
Kidney
 Incision 50010 – 50135
o Percutaneous Nephrolithomy (nephrolithotripsy) – method of treating kidney stones that
is invasive and usually uses ultrasound – 50590 or 52353
o PCNL (Percutaneous Nephrostolithotomy) or a Pyelostolithotomy – 50080 and 50081
 Watch codes for size of stone removed
o Retroperitoneal – area behind the abdominal cavity (read instructions preceding 50010)
o Nephrostomy – procedure used to decompress the renal system by means of inserting
a catheter into the kidney while leaving the other end of the catheter outside the body to
temporarily drain the kidney
o Nephrotomy – exploration of the inside of the kidney
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o Nephrolithotomy – removal lf calculus (kidney stone) 50060 - 50075
o ESWL (Extracorporeal Shock Wave Lithotripsy) 52352
 50590 – Lithotripsy
 52353 – Cystourethorscopy with lithotripsy
 Excision –50200 – 50290
o Watch for different types of incisions and approaches
o Nephrectomy – removal of either a part or the whole of a kidney 50220 – 55240, 50343,
50545 – 50548
o Ablation – cutting away or erosion of tissue 50593, 50542
 Watch the method used
 Renal Transplantation –50300 – 50380
o Read guidelines in CPT Book
 Allotransplantation – transfer of tissue or an organ between 2 people who are not
related
 Autotransplantation (aka autograft or autotransplant) – transfer of tissue from one
part of a person’s body to another part of that person’s body
o Backbench work to prep for surgery:
 Open organ retrieval from a deceased 50300 or living donor (50320) and
laparoscopic organ retrieval from a living donor (50547)
 Standard preparation depending if the donor is deceased (50323) or living
(50325)
 Transplant services – 50360 or 50365
 Watch for use of modifier -50
 Introduction –Renal Pelvis Catheter Procedures
o Internally Dwelling – 50382 - 80386
o Externally Accessible – 50387 – 50389
o Other Introduction Procedures – 50390 – 50398
Medical Billing and Coding
Chapter 19
 Repair 50400 – 50540
o Watch for different types of incisions and approaches
o Pyeloplasty – surgical procedure for an obstruction of the ureteropelvic junction (UPJ)
o Calycoplasty – repair of the cup-shaped structure of the kidney
 Laparoscopy 50541 – 50549
 Endoscopy 50551 – 50593
o Read your notes
 Other procedures 50590 – read diagram
Ureter - 50600 – 50980
o Category codes are based on procedure
o Ureter – tube leading from the kidney to the bladder
 Incision – 50600 – 50630
 Excision – 50650 – 50660
o Bladder Cuff – the tissue that connects the ureter to the bladder
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 Introduction – 50684 – 50690
o Includes injection procedures, manometric studies, and changes of tubes and/or stents
 Manometric studies – tests to measure kidney and ureter flow and pressure.
 Repair – 57000 – 50940
o Terminology
 Ureteroplasty – plastic repair of the ureter
 Ureterolysis – freeing fibrous tissue
 Revisions of surgical openings
 Ureteropyelostomy – connection of the upper ureter to the renal pelvic
 Ureterocalicostomy – connection of the upper ureter to the renal calyx
 Ureteroureterostomy – bypass of obstructed ureter
 Other repairs also
 Laparoscopy – 50945 – 50949
 Endoscopy – 50951 – 50980
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Medical Billing and Coding
Chapter 19
Bladder 51020 – 52355
Incision – 51020 – 51102
Terminology
o Aspiration - removal of urine from the bladder
 May use a trocar (a sharply pointed surgical instrument) or a intracatheter (plastic
tube with a needle on the end)
o Cystotomy 51020 -51050
 – Fulgurate (use of an electrical current)
 Cystolithotomy – removal of calculus
o Transvesical Ureterolithotomy 51065
 Electrohydraulic Fragmentation
 Excision 51500 – 51597
o Urachal Sinus - congenital abnormality in which prenatal tissue remains, causes
drainage to the umbilicus, and results in infection – 51500
o Cystotomies and cystectomies – 51520 – 51596
o Pelvic exenteration (aka TPE – total pelvic exenteration) – removal of the pelvic organs
and adjacent structures due to malignancy – 51597
o Hysterectomy – 51597
 Introduction 51600 – 51720
o Injection procedures – 51600 – 51610
o Insertion of bladder catheters
 Non-indwelling – 51701
 Temporary indwelling – 51702, 51703
 Instillation – procedure that is performed for bladder cancer where the
anticarcinogenic agent is introduced into the bladder by means of a catheter.
 Ex. Mitomycin is used. Admin code is 51720 and the drug is a “J” code
from the HCPCS book. The diagnosis is normally 188.9
 Urodynamics 51725 – 51798
o Pertains to the flow of urine
o Uses the “TC” and “26” modifiers
 Repair / Laparoscopy 51800 – 51980, 51990 - 51999
o Stress incontinence – 51840 and 51840
 Also check the Female Genital System subsection under the “Vagina”
subheading 57287 – 58729
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Medical Billing and Coding
Chapter 19
 Endoscopy – Cystoscopy, Urethroscopy, Cystourethroscopy – 52000 – 52010
o Cystourethroscopy – diagnostic procedure to assess lower urinary tracts symptoms
(LUTS)
 Reported only if it is the only procedure performed during the operative session
This gentleman has worsening bilateral hydronephrosis. He did not have much of a post void
residual on bladder scan. He is taken to the operating room to have a bilateral cystoscopy and
retrograde pyelogram. The results come back as gross prostatic hyperplasia.
A.
B.
C.
D.
52005, 600.3 (cyst of the prostate)
52000, 591 (Hydronephrosis), 600.9 ( Hyperplasia of prostate unspecified)
52005-50, 600.91 (Hyperplasia of prostate, unspecified, with urinary retention), 591
52000-50, 591, 600.9
52000 – Cystourethroscopy (separate procedure) (diagnostic only)
During an examination, the urologist may take the following steps: remove either bladder or kidney
stones; gather tissue samples; and treat any suspicious lesions. In order to perform x-ray studies
(retrograde pyelogram), a harmless dye is injected into the ureters by way of a catheter which is
passed through the previously placed cystoscope. After completion of all needed tests, the
cystoscope is removed.
http://www.thirdage.com/health-wellness/cystoscopy-cystourethroscopy
52005 – Cystourethroscopy, with ureteral catherization, with or without irrigation, installation or
ureteropyelography, exclusive of radiologic service;
 Transurethral Surgery 52204 – 52355
Cystoscopy Surgery Video
http://www.youtube.com/watch?v=t7ozFUnsckI
o Urethra and Bladder - 52204 – 52318
 Terminology
 TURBT – Transurethral Resection of a Bladder Tumor
 Watch for lesion size removal codes
o Ureter and Pelvis – 52320 – 52355
 This section includes insertion and removal of temporary stents
 Also deals with indwelling stents – Watch coding verbage used
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Medical Billing and Coding
Chapter 19
Preoperative Diagnosis: Possible recurrent transitional cell carcinoma of the bladder
Post Operative Diagnosis: No evidence of recurrence
Procedure Performed: Cystoscopy with multiple bladder biopsies
Procedure Note: The patient was given a general mask anesthetic, prepped, and draped in the
lithotomy position. The 21-Frence cystoscope was passed into the bladder. There was a hyperemic
area on the posterior wall of the bladder, and a biopsy was taken. Random biopsies of the bladder
were also performed. This area was fulgurated. A total of 7 sq cm of bladder fulgurated (to destroy
by contact with electric sparks generated by a high-frequency current). The catheter was left at the
end of the procedure. The patient tolerated the procedure well and was transferred to the recovery
room in good condition. **********The pathology report indicated no evidence of recurrence.
A. 52224, 595.9 (Cystitis (bacillary) (colli) (diffuse) (exudative) (hemorrhagic) (purulent)
(recurrent) (septic) (suppurative) (ulcerative), V10.51 (Personal history of malignant neoplasm
of bladder)
B. 51020, 52204, V16.52 (Family history of malignant neoplasm of bladder)
C. 52234, V10.51
D. 52224 x 4, 236.7 (Neoplasm of uncertain behavior of bladder)
52224 – Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of
MINOR (less than 0.5 cm) lesion(s) with or without biopsy
52234 – Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection
of; SMALL bladder tumor(s) (0.5 c, up to 2.0 cm)
Vesical Neck and Prostate – 52400 – 52700
o See Male Genital System for procedure codes
Urethra (53000 – 53899)
 Incision 53000 – 53085
o Terminology
o Meatotomy – surgical incision of the meatus
o Skene’s Glands – paraurethral of the lesser vestibular glands -53270
 Excision 53200 – 53275
 Terminology
o Marsupilzation – creating a pouch
o Urethrectomy – total surgical removal of the urethra
 Female– 53210
 Male - 53215
 Repair 53400- 53520
o Terminology
o Urethromeatoplasty – repair of the meatus and the urethra 53450, 53460
 Manipulation 53600 – 53665
M. Cremers - 2010
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o Deals with dilating or stretching a passage that has narrowed. (Word association - Think
of a woman in labor who passage dilates or stretches in order to give birth to a baby)
 Other Procedures – 53850 – 53899
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