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 [email protected] or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.
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