AHA Coding Clinic® for ICD-9 - 2009 Issue 1; Ask the Editor

Urethral Trauma Due to Eroded Artificial Urinary Sphincter

The patient had a history of prostate cancer, status post radical retropubic prostatectomy with artificial urinary sphincter insertion. The patient had been doing well; however, following a recent cardiac catheterization and placement of a Foley catheter, he started to experience urinary incontinence. Evaluation of this problem revealed that the artificial urinary sphincter cuff had eroded into the urethra, damaging the urethra and causing urinary incontinence. Therefore, the patient underwent removal of the artificial urinary sphincter and urethroplasty. In his final diagnostic statement the provider documented, “Urethral trauma, urethral erosion due to eroded artificial urinary sphincter.” What are the appropriate diagnosis and procedure code assignments? Should code 867.0, Injury to bladder and urethra, be assigned to describe the urethra trauma caused by the eroded urinary sphincter cuff? ...

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