AHA Coding Clinic® for HCPCS - 2018 Issue 1; Ask the Editor

Release of stenosis in neobladder

A patient with a history of bladder cancer, status post radical cystectomy, a T-pouch to the urethra, and a history of problems with afferent valve stenosis, is now being seen at our facility for surgical management of the stenosis in the neobladder. Over the last 15 years or so, he was doing well until he developed renal insufficiency and complete obstruction of both kidneys with an inability to pass urine into his pouch. The patient underwent a laser incision and balloon dilation of the stenotic afferent valve with placement of a ureteral stent. Is it appropriate to assign CPT code 53899 to capture the release of stenosis in the neobladder via laser and balloon dilation in addition to CPT code 52332, Cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type), for the placement of the stent? ...

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