Coping with Coding has been developed to provide you with educational articles focusing on common coding questions and issues facing many Urologists. 

Proper Coding for the Treatment of Bladder Neck Contraction
by Michael A. Ferragamo MD, FACS

Proper coding for the treatment of bladder neck contracture has produced some confusion as to the correct CPT code to document and use in the various clinical scenarios. Coding for this treatment should be based on two facts. One is the etiology of the bladder neck contraction and secondly the procedures used to correct the obstruction.

If this is a congenital problem (ICD-9 diagnostic code 753.6 atresia and stenosis of urethra and bladder neck, congenital obstruction of the bladder neck, use CPT code 52400 for the cystourethroscopy with incision, fulguration or resection...) of the bladder neck. 

In the young adult male with a bladder neck contracture ( ICD-9 596.0 bladder neck obstruction, acquired,) secondary to a localized prostatic hyperplaisia at the bladder neck, use CPT code 52450-52 indicating incision(s) of the bladder neck or 52500, transurethral resection of the bladder neck. For the first coding example add modifier -52, reduced service,  to the 52450 (transurethral incision(s) of the prostate) to indicate incision(s) only at the bladder neck and not through the entire prostatic urethra.

For postoperative bladder neck contractures such as following an extensive TURP especially at the bladder neck, one may use CPT code 52640, transurethral resection of postoperative bladder neck contracture. If one only performs an incision or incisions at the bladder neck, add modifier -52 to indicate a reduced service as stated above code CPT 52640-52 to indicate this reduced service.

The "bladder neck contracture" following a radical prostatectomy is in reality a stricture at the bladder urethral anastomosis. An incision or incisions here should be coded with CPT code 52276, visual, optical internal urethrostomy.

These incisions may be cold cut, hot cutting, or laser induced incisions.

Michael A. Ferragamo, MD is a practicing urologist, editor of Urology Coding Alert, a monthly newsletter on urology coding published by The Coding Institute of Naples, Florida. and the writer of these coding articles.  Dr. Ferragarno is a nationally known coding expert in urology and would be happy to help with any coding problems you may have. He may be reached at (516) 741-0118, (516) 746-5550, (516) 721-8149 or by e-mail at nysuscoding@nysurologicalsociety.org.