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Editor's Note: This article by Paul Cadorette, director of education for mdStrategies, originally appeared in The Coding Advocate, mdStrategies free monthly newsletter. Sign-up to receive this newsletter by clicking here.
When an individual has an involuntary leakage of urine caused by coughing, sneezing or physical activity, this would be known as stress urinary incontinence. In women, the urethra is supported by pelvic floor muscles and connective tissue within the vagina, but during childbirth these muscles and tissues can become stretched and lack the necessary strength to close off the urethra during a stress event. Lack of support can also lead to a urethral prolapse.
A common and minimally invasive technique called tension free TVT (transvaginal tape) procedure can be performed to help alleviate some of the symptoms associated with SUI. The main component of the procedure is placing a strip of mesh tape that is inserted through an incision in the vagina (transvaginal) and up under the mid-urethra. Once in place under the urethra, instruments are used to bring the tape out through the surface skin by way of two small incisions located in the suprapubic area. The sling can then be adjusted and as the surgical wound heals, tissue will grow within the mesh tape holding it in place. The tape remains "tension free" (it does not put any pressure on the urethra) until a stress event. For example, when you sneeze, muscles in the pelvic area contract and pull upward — this is when the tape will engage the urethra and provide support that helps to contain any urine leakage.
The procedure describe above would be reported with CPT code 57288 — Sling operation for stress incontinence. Once the sling has been placed, the physician may perform a diagnostic cystoscopy to confirm that there wasn't any injury to the urethra or bladder while placing the mesh tape. The cystoscopy would not be additionally reported based on information that can be found in CPT Assistant (Oct. 2000). A sling can also be placed using a laparoscopic approach (CPT 51922), and when a removal or revision procedure is performed, the coder should report CPT 57287.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
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