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How to secure payment for bladder repair
When inadvertent injury to the bladder occurs during cesarean delivery, additional payment for the repair may be forthcoming if the repair is correctly coded and billed. The repair would be considered a multiple procedure during the operative session, and reimbursement would be at a reduced rate, based on intraoperative work only (usually 50% of the allowable for the additional code reported).
If cystorrhaphy is required, you have two codes from which to select:
| 51860 | Cystorrhaphy, suture of bladder wound, injury or rupture; simple (22.39 RVUs) |
| 51865 | Cystorrhaphy, suture of bladder wound, injury or rupture; complicated (27.10 RVUs) |
In most cases, the repair will involve simple suturing; therefore, CPT code 51860 will be the procedure most frequently reported. The linking diagnosis for this procedure code is 998.2, Accidental puncture or laceration during a procedure.
The basic rule in coding is to list the code with the highest value first on the claim to ensure that it is paid at 100% of the allowable. In this case, the codes available to report a cesarean delivery (59510–59515 and 59618–59622) all have a higher RVU than the simple bladder repair code 51860. Therefore, correct billing would be:
| 59510 | (linked to an ICD9 code that specifies the reason for the cesarean, such as 649.81 [Onset (spontaneous) of labor after 37 completed weeks of gestation but before 39 completed weeks of gestation, with delivery by (planned) cesarean section; delivered, with or without mention of antepartum condition] or 654.21 (Previous cesarean delivery; delivered, with or without mention of antepartum condition) |
| 51860–51 | (linked to code 998.2) |
Note that payment for bladder repair may also be forthcoming if the laceration occurs during any other type of surgery, and the coding format would be the same for the repair. However, Medicare will not reimburse the surgeon who caused an iatrogenic injury to repair it during the surgical session at which it occurred.
Melanie Witt, RN, CPC, COBGC, MA
Independent Coding and Documentation Consultant
Former Program Manager
Department of Coding and Nomenclature
American Congress of Obstetricians and Gynecologists
Washington, DC
Dr. Barbieri responds Suggestions are appreciated
On behalf of the readers of OBG Management, I thank Dr. Shirley, Dr. Culotta, and Dr. Porges for their expert clinical suggestions.
Dr. Shirley points out that it is important not to bunch and pucker the bladder repair, and interrupted sutures would reduce the risk of this problem.
I agree with Dr. Culotta’s suggestion to use methylene blue (or indigo carmine) to assess bladder integrity. Because methylene blue can cause pelvic tissues to maintain a bluish hue for a considerable period of time, some surgeons prefer to avoid it. Indigo carmine is less likely to produce this effect.
Dr. Porges observes that a cystotomy is helpful because it allows the surgeon to directly assess the integrity of the trigone. Far from posing a “problem,” a cystotomy in the dome of the bladder actually creates an advantage, permitting more complete assessment of urinary tract integrity.
I appreciate Ms. Witt’s advice on procedure coding for cystotomy repair.
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