Stress Urinary Incontinence –
Surgical Intervention Coding for Urinary Sling
March 2018
Urinary
incontinence is the unintentional loss of urine.
Stress Urinary Incontinence (SUI) is what occurs when there is stress or
movement/ activity put upon your bladder.
This activity can be something as minor as laughing, coughing, sneezing,
running or lifting. SUI is not a condition related to “stress” in
a psychological way, such as a person who is suffering from a mental anxiety or
issue, SUI is purely related to a
movement/activity that is related to a physical stress upon the body. .
There are four main types of urinary
incontinence
Stress urinary incontinence is defined as the
unintentional loss of urine caused by the bladder muscle contracting, involuntarily
with physical movement. Some patients
also experience a sense of urgency. SUI
is much more common in women than men, however, the most common cause of SUI is a pelvic floor disorder, damage to,
or weakening of the soft tissue that normally supports the urinary
organs.
SUI is a direct result of the urinary sphincter muscle that controls the urethra becomes weakened, in addition
to the weakening of the soft tissues.
When both the muscle and the soft tissue supports become weak, this
allows the release of urine to happen during a “stressful, physical event” such
as laughing, coughing, sneezing, etc.
Coding interventions
SUI
surgery is not exclusive just to the Urology specialty, many gynecologists also
perform surgical intervention for SUI in women.
CPT has given us many code choices for surgical intervention of
SUI. Currently the most commonly used for
treatment in both men and women are the surgical procedures for a urinary “sling”.
When
a sling procedure is performed, the surgeon uses the patient's own tissue (or
other type of supply) to essentially
“sling up” or “pex up” the uretha by inserting a strip of additional material/tissue
to create an additional support system for the urethra. This support is sewn into the pelvic area to
help keep the urethra in the proper physical location.
Slings
can be used for both men and women with SUI.
Urinary
Sling procedures can be performed as an open procedure or as a laparoscopic
procedure. The two most common types of
bladder slings are the TOT sling (transobturator tape sling) and the TVT sling
(tension-free vaginal tape sling). The TOT
sling and the TVT sling are normally performed as a quick 30 minute, outpatient
procedures with a high success rate of nearly 90%. The incisions are small
(less than one centimeter) and recovery times are quick. However, these procedures can be done in
coordination with other surgical procedures.
The
CPT codes below are those that are specifically related to SUI.
·
57288 Sling
operation for stress incontinence (eg, fascia or synthetic) - Open Approach
·
57287 Removal or
revision of sling for stress incontinence (eg, fascia or synthetic) – Open or
laparoscopic Approach
·
53440 Sling
Operation for correction of male urinary incontinence (eg, fascia or synthetic)
– Open Approach
·
53442 Removal or
revision of sling for male urinary incontinence (eg, fascia or synthetic) –
Open Approach
·
51990 Laparoscopy,
surgical; urethral suspension for stress incontinence
·
51992 Laparoscopy,
surgical; sling operation for stress incontinence (eg, fascia or synthetic)
·
10120 Incision
and removal of foreign body, subcutaneous tissue – simple
·
10121 Incision
and removal of foreign body, subcutaneous tissue - complicated
When
coding for these procedures, the coder need to carefully review the operative
report to double check if the procedure is being performed laparoscopically or
as an open procedure. The codes for the
open approach include the 57287, 57288, 53440 and 53442. The physician/surgeon may state this is a
“mini-laparotomy” however, this still means the surgical approach is
“open”. If the physician documents the
procedure was performed with a laparoscope, the codes 51990 and 51992 would be
the correct codes to choose. If the
sling is removed laparoscopically, the 57287 is the correct code to use
regardless if the procedure was performed as an open procedure or a
laparoscopic procedure.
Codes
53440, 53442, 51990, 51992, 57287 and 57288 all have a 90 day global period.
Should a sling revision be surgically necessary during the global period, you
will need to add modifier -78, to your
code, as this is an unplanned return to the OR for a related procedure.
In
addition, revision of an SUI sling procedure code(s) 57287 or 53442 both of these codes include replacement procedure of a sling
(codes 57288 or code 53442) when performed on the same date of service. These codes are bundled in the CCI bundling
edits from CMS, and do not allow a modifier to over-ride the bundling
edit.
The
usage of code 10120 and 10121 have become common when physicians have “removed”
portions of a mesh erosion that has eroded into the subcutaneous tissues around
the abdomen and groin areas. These
integumentary codes are very specific if the mesh is only being removed from
the subcutaneous tissue, and not a full excision or revision of the sling
itself. When reporting CPT code 10120 or 101210 you will need to add
either a modifier -58 or modifier -78 if the mesh erosion is treated in the
office/procedure room. The verbiage of
codes 10120/10121 strictly denotes in the definition as a removal of foreign
body“subcutaneous” tissue.
Unfortunately,
CPT does not give clear guidance as to what constitutes “simple” versus
“complicated” when it comes to codes 10120 and 10121. So if you choose to use CPT Code 10121
(incision and removal of foreign body, subcutaneous tissues; complicated) when
an incision is necessary to remove the foreign body you will need to educate
the physician to document in the operative note that the removal was
“complicated”. In addition, the
physician should also document “why” the removal was complicated, with the
usage of additional terms such as; embedded, deep, size, location,
abnormality. It may necessitate having
the physician document the amount of time spent in the removal to support the usage of the “complicated” code
10121, rather than the “simple” code 10120.
Operative Report SPARC
suburethal Sling
PROCEDURE: SPARC suburethral sling
PREOPERATIVE
DX: Stress urinary incontinence;
hypermobility of urethra
POSTOPERATIVE
DX: Stress urinary incontinence;
hypermobility of urethra.
OPERATIVE
PROCEDURE: SPARC suburethral sling.
FINDINGS
& INDICATIONS: Outpatient evaluation was consistent with urethral
hypermobility, stress urinary incontinence. Intraoperatively, the bladder
appeared normal with the exception of some minor trabeculations. The ureteral
orifices were normal bilaterally.
DESCRIPTION
OF OPERATIVE PROCEDURE: This patient was brought to the operating room, a
general anesthetic was administered. She was placed in dorsal lithotomy position.
Her vulva, vagina, and perineum were prepped with Betadine scrubbed in
solution. She was draped in usual sterile fashion. A Sims retractor was placed
into the vagina and Foley catheter was inserted into the bladder. Two Allis
clamps were placed over the mid urethra. This area was injected with 0.50%
lidocaine containing 1:200,000 epinephrine solution. Two areas suprapubically
on either side of midline were injected with the same anesthetic solution. The
stab wound incisions were made in these locations and a sagittal incision was
made over the mid urethra. Metzenbaum scissors were used to dissect bilaterally
to the level of the ischial pubic ramus. The SPARC needles were then placed
through the suprapubic incisions and then directed through the vaginal incision
bilaterally. The Foley catheter was removed. A cystoscopy was performed using a
70-degree cystoscope. There was noted to be no violation of the bladder. The
SPARC mesh was then snapped onto the needles, which were withdrawn through the
stab wound incisions. The mesh was snugged up against a Mayo scissor held under
the mid urethra. The overlying plastic sheaths were removed. The mesh was cut
below the surface of the skin. The skin was closed with 4-0 Plain suture. The
vaginal vault was closed with a running 2-0 Vicryl stitch. The blood loss was
minimal. The patient was awoken and she was brought to recovery in stable
condition.
Cpt
Code:
57288 Sling
operation for stress incontinence (eg, fascia or synthetic) - Open Approach
ICD-10CM
:
N39.3 Stress incontinence
(female) (male)
N36.41 Hypermobility of urethra
Operative Report Male Sling
General anesthesia
administered and patient positioned in the dorsal lithotomy position. A 16F
Foley catheter placed to drain the bladder. Peri-operative antibiotics are
administered. A vertical incision is
made to the perineum approximately 1-2 cm inferior to the penoscrotal junction
and carried 1 cm anterior to the rectum. Dissection is continued through
Colles' fascia and the underlying bulbocavernous muscle. Sharp dissection is
continued until the spongiosal bulb has been freely dissected. The perineal
body is identified and dissection is continued proximally approximately 4 cm.
Attention is then focused
on identification and marking of the anatomical and landmarks for placement of
the surgical passers. The adductor longus tendon is identified and marked, each
of the two trochar insertion sites are then marked, and insertion is performed
just lateral to the inferior pubic ramus. The skin sites are incised and
surgical passer placement is performed.
A surgical finger is placed inside the perineal dissection and to
identify the inferior pubic ramus where the passer will exit. Under manual
guidance, the passer is advanced through the medial aspect of the obturator
foramen, exiting at the level of the perineal body lateral to the spongiosal
bulb. Care is taken to maintain a 45º
angle during passage, therefore completing the trochar rotation. The passer is
then hooked to the respective sling arm, which is then pulled though the
obturator foramen to exit via the skin incision bringing the mesh into place.
The mesh is then checked to ensure that twisting has not occurred.
Subsequently, the opposite passer is placed in an identical fashion and the
sling is pulled into place.
The central mesh anchor is
sutured into place, with the posterior aspect fixed to the spongiosal tissue at
the most proximal aspect of the bulbar dissection. The distal anchor is then
sutured to the spongiosal tissue, each performed with 3-0 vicryl suture. Tensioning of the sling is now performed, by
pulling the mesh arms so the bulb of the corpus spongiosum is brought cephalad
by the sling. Sling tensioning is
increased until 3-4 cm of proximal urethral movement is obtained. Bulbar
suspension is confirmed by measuring proximal movement from the initial point
of fixation to the perineal body. A
cystourethroscopy is then performed to rule out any urethral or bladder injury.
The arms of the mesh are cut below skin level and skin incisions closed with
Dermabond. The perineal dissection is
then closed with a standard 3-layer closure with absorbable suture.
Cpt
Code:
53440 Sling
Operation for correction of male urinary incontinence (eg, fascia or synthetic)
– Open Approach
ICD-10CM
:
N39.3 Stress incontinence
(female) (male)
Operative
Report – Laparoscopic removal
A
laparoscopic approach was utilized to remove the polypropylene mesh sling from
the retropubic space and , bladder, We entered the peritoneal cavity through
the umbilicus and then placed 3 ancillary ports under direct vision . A 10-mm port is placed in the
left paramedian region for suturing, and 5-mm ports are placed suprapubically
and in the right paramedian region. After the pneumoperitoneum was created, and
adhesiolyis was performed, and taken down, the bladder is filled in a
retrograde manner with 200 mL to 300 mL of saline, allowing for identification
of the superior border of the bladder edge. Entrance into the space of Retzius
was accomplished with a transperitoneal approach using a Harmonic scalpel. The incision was made approximately 3 cm
above the bladder reflection, beginning along the medial border of the right
obliterated umbilical ligament. After entering the space of Retzius the pubic
ramus was visualized; the bladder drained to prevent injury during dissection.
Separation of the loose areolar and fatty layers using blunt dissection
develops the retropubic space, and dissection is continued until the retropubic
anatomy is clearly visualized. Identification of the sling mesh was made where
it touches the pubic rami, approximately
3 cm lateral from midline. Once
identified, the mesh was grasped and excised from the anterior abdominal wall
and then peeled free of the pubic rami periosteum. Dissection was then
continued down along the mesh toward the bladder and pubocervical fascia.
Extensive scarring was encountered, and the mesh was cut out with the scarred
tissue. In addition, the mesh was eroded
into the bladder, and the dissection was continued down to where the mesh appeared
to be eroded into the bladder. The mesh was
removed but erosion was not found to be
in the bladder. Dissection was continued down to and through the pubocervical
fascia on both sides. An incision was then made suburethrally, and the remaining
mesh below the urethra identified, cut in the midline, and freed up allowing
removal of the entire portion of the mesh sling. All laparoscopic surgical devices were
removed and accurate sponge and surgical devices accounted for. Patient then taken to the recovery area, and
will be discharged when stable.
Cpt
Code:
57287 Removal or revision of sling for stress
incontinence (eg, fascia or synthetic) – Open or laparoscopic Approach
ICD-10CM
:
T83.711D Erosion of implanted vaginal mesh to surrounding
organ or tissue; subsequent
encounter
Wrap up
The biggest challenge of coding for SUI is ensuring
that the correct codes were chosen for either open or laparoscopic
approach. In addition to ensuring that
your codes for CPT are correct, but double check your ICD-10cm diagnoses for
accuracy. And with all claims, follow
them to ensure that they were submitted in a timely manner, but were also
reimbursed correctly. If not, then file
an appeal for readjudication or peer review as necessary.
Lori-Lynne
A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 cm/pcs Ambassador/trainer is an
E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA
Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN
office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology,
Urology, and general surgical coding.
She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information
on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
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