CHAPTER 24
URINARY AND MALE
GENITAL SYSTEMS
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Slide 1
Urinary System
• Anatomic divisions
– Kidney
– Ureters
– Bladder
– Urethra
• Procedures on prostate
in either Urinary or
Male Genital System
(Cont’d…)
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Figure: 24.1
Slide 2
Urinary System
(…Cont’d)
• Further divided by procedure
– Incision
– Excision
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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
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Figure: 24.6
Slide 4
Incision (50010-50135)
• Caution:
– Kidney located in retroperitoneal 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)
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Slide 5
Procedures
• Nephrostomy (50040): Insertion of catheter into
kidney with one end in kidney and one end
outside body
• Nephrotomy (50045): Exploration of inside of
kidney
– No definitive procedure
– Verify all CCI code edits to prevent unbundling
• Nephrolithotomy (50060-50075): Removal of
calculus
(Cont’d…)
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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
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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
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Slide 8
Renal Transplant (50300-50380)
• Backbench work
– Retrieval of organ
• Deceased (50300)
• Living (50320, open; 50547, laparoscopy)
– Preparation of organ
• Deceased (50323)
• Living (50325)
– Transplantation
• Without nephrectomy, 50360
• With nephrectomy, 50365
• Add -50 for bilateral procedure
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Slide 9
Introduction (50382-50398)
• Aspirations
• Catheters and injections for radiography
• Insertion of guidewires
• Tube changes
• Usually reported with radiology component
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Slide 10
Repair (50400-50540)
• Pyeloplasty
– Repair of ureteropelvic junction (UPJ)
– Simple 50400
– Complicated 50405
• Closure of fistula (abnormal opening)
– 50520-50526
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Slide 11
Laparoscopy (50541-50549)
• Ablation of renal
– Cyst (50541)
– Lesion (50542)
– Cryoablation (50250)
– Percutaneous (50593)
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Slide 12
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 purpose
– Biopsy
– Removal of foreign body/calculus
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Slide 13
Ureter
• Divided based on type of procedure
– Incision
– Excision
• Laparoscopy codes describe surgical
procedures
• Codes may be bilateral or unilateral
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Slide 14
Incision (50600-50630)
• Report open procedures
– Explore or drain (50600)
– Insert indwelling stent (50605)
– Remove calculus (50610-50630)
• Based on location of upper third, middle third, or
lower third
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Slide 15
Excision and Introduction
(50650-50690)
• Excision
– Ureterectomy (50650, 50660)
• Bladder cuff excision or total excision
• Introduction
– Reports injections, manometric (measures
pressure) studies, change of stents/tubes
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Slide 16
Laparoscopy and Endoscopy (5094550980)
• Laparoscopic placement of ureteral stent
(50947, 50948)
• Endoscopy codes (50951-50980) for
procedure through established stoma
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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
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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
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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
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Slide 20
Urodynamics (51725-51798)
• Procedures relate to motion and flow of urine
(motor & sensory function)
• Used to diagnose urine flow obstructions
• Bundled: All usual, necessary instruments,
equipment, supplies, and technical assistance
• Always code urodynamic code in addition to all
other cysto codes if both are performed
• Modifier -51 is reported for multiple procedures
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Slide 21
Repair and Laparoscopy
• Repair (51800-51980)
– Cystoplasty
– Cystourethroplasty
– Vesicourethropexy/uretropexy (urinary
incontinence)
• Laparoscopy (51990-51999)
– Stress incontinence procedures
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Slide 22
Endoscopy—Cystoscopy, Urethroscopy,
Cystourethroscopy
• 52000-52010
• Many combination codes
• Notes before 52000 indicate that included are:
– Meatotomy
– Urethral calibration
– Urethral dilation
– Urethroscopy
– Cystoscopy
– Ureteral catheterization, etc.
(Cont’d…)
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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
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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
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Slide 25
Vesical Neck and Prostate
(52400-52700)
• Contains codes for transurethral
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
incision in the perineum
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Slide 26
Urethra
• Excision (53200-53275)
– 53210 female
– 53215 male
• Repair (53400-53520)
– Urethroplasty may be one or two stage
– Some codes divided based on male/female
• Manipulation (53600-53665)
– Stretches of narrowed passage
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Slide 27
Male Genital System Anatomic
Subsection
• Penis
• Testis
• Epididymis
• Tunica Vaginalis
• Scrotum
• Vas Deferens
• Spermatic Cord
• Seminal Vesicles
• Prostate
Figure: 24.10, A & B
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Slide 28
Subsection Format
• Format:
– Incision
– Destruction (method used & if simple or extensive)
– Excision
– Introduction
– Repair
– Manipulation
– Suture
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Slide 29
Biopsy Codes
• Located in subheading to which refer
– Example Biopsy codes in subheadings:
• Epididymis (Excision)
• Testis (Excision)
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Slide 30
Penis
• Incision category differs from
Integumentary System codes
• Penis Incision codes for deeper structures
– Example: erectile tissue
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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
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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
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Slide 33
Peyronie Disease
• Curvature of penis
• Result of plaque formation
• Surgical removal of plaque
(54110-54112)
• 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
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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)
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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
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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
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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
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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…)
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Slide 39
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 hernia
• Repair (54600-54680)
– Orchiopexy: Moving and fixation of testis to scrotal sac
• Abdominal approach: 54650
• Laparoscopic: 54692
• Code selection based on approach (inguinal, scrotal, or abdominal)
• Check CCI edits for bundled procedures
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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)
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Slide 41
Tunica Vaginalis
(55000-55060)
• Serous sheath of testis
• Site of hydrocele (fluid collection) (unilateral or
bilateral)
– Treatment options, such as aspirate, inject, excise,
repair
– Repair: Bottle type repair (55060)
• Drain
• Reposition
• Catheter left in place
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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
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Slide 43
Vas Deferens
(55200-55450)
• Tube that conducts sperm from testes to ejaculatory duct
and urethra
• 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 -50
• Introduction: Dye for radiographic procedure
• Repair: Remove obstruction, anastomose ends, semen
sampling included
– Operating microscope: 69990
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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
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Figure: 24.13
Slide 45
Seminal Vesicles
(55600-55680)
• Pair of bands, posterior to bladder
• Provide majority of semen fluid
• Incision: Vesiculotomy
– Simple 55600, complicated 55605
• Excision: Vesiculectomy
– For removal of tumor, calculus, or other obstruction
– 55650, any approach
– Add -50 for bilateral
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Slide 46
Prostate (55700-55899)
• BPH, Benign Prostatic Hyperplasia
– Enlargement of the prostate
• Treatment options:
– Urethral stent keeps urethra open at level of prostate
• 52282, permanent
• 53855, temporary
– TUMT (53850) microwave heat
– TUNA (53852) radiofrequency
• Each code description lists approach and
bundled procedures, if appropriate
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Slide 47
Incision (55700-55725)
• Prostate Biopsy
– Needle or punch, 55700
– 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
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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
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Slide 49
Prostatectomy
• Two types of codes:
– Coagulation (52647)
– Vaporization (52648)
• Vaporization may be with or without
resection
(Cont’d…)
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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
• TULIP (non-contact) no direct view by surgeon
• VLAP (non-contact) direct view by surgeon
• ILCP (contact) no direct view by surgeon
(Cont’d…)
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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)
– HoLEP or THLR (contact) laser resects tissue with
holmium laser fiber
(Cont’d…)
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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
• Second based on extent
– Subtotal or radical
(Cont’d…)
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Slide 53
Prostatectomy
(…Cont’d)
• LRP (55866)
• Laparoscopic = minimally invasive
• RAP (no CPT code)
– Use with 55866 with -22
– www.davinciprostatectomy.com/video.html
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Slide 54
Brachytherapy (55860-55865)
Brachytherapy for prostate cancer
• Methods
– High dose, temporary
method
– Low dose, permanent
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
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Slide 55
Conclusion
CHAPTER 24
URINARY AND MALE
GENITAL SYSTEMS
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Slide 56