AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2019 Issue 1; Ask the Editor

Young-Dees-Leadbetter Bladder Neck Reconstruction

A 9-year-old girl with a history of cloacal anomaly has persistent stress incontinence despite previous urethral mobilization and vaginoplasty. She presents for Young-Dees-Leadbetter bladder neck reconstruction. During surgery, the bladder was opened to expose the bladder neck. Upon opening the bladder, right ureteral re-implantation was performed to allow for longer bladder neck reconstruction. The trigone mucosa was incised on either side of the midline to create a strip of mucosa for creation of a neo-urethra. A wedge of trigone mucosa was excised using electrocautery resulting in muscle flaps. The muscle was incised transversely at the cephalad margin of the mucosal excision on either side. The central mucosal strip was then tubularized over a catheter, using sutures. The lateral flaps of trigone muscle were then approximated over the neo-urethra in an overlapping fashion. How is this bladder neck reconstruction coded? ...

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