How To Use CPT Code 51596

CPT 51596 describes the complete removal of the urinary bladder and adjoining organs, along with the construction of a continent diversion using any segment of the small and/or large intestine. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 51596?

CPT 51596 can be used to describe the surgical procedure in which the provider completely removes the urinary bladder and adjoining organs. This procedure is typically performed when there is bladder cancer found in multiple areas of the bladder or when there is a recurrence of cancer. Additionally, the procedure involves the rerouting of urine from the body using any segment of the small and/or large intestine to construct a neobladder.

2. Official Description

The official description of CPT code 51596 is: ‘Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder.’

3. Procedure

1. The provider places a Foley catheter in the urethra and inflates the balloon with sterile saline.
2. An incision is made from the navel to the pubic bone to access the abdominal and pelvic cavities.
3. The provider carefully removes the bladder and any adjoining organs, such as the uterus, ovaries, fallopian tubes (in female patients), prostate, seminal vesicles, and vas deferens (in male patients).
4. The provider decides on the method to reroute the flow of urine out of the body, which may involve creating a continent catheterizable stoma.
5. If a continent catheterizable stoma is chosen, a small section of the intestines is used to create a pouch that acts as a bladder to store urine.
6. A one-way valve is inserted where the small intestine joins the large intestine to prevent urine from draining out of the pouch.
7. A small opening, called a stoma, is made in the abdominal wall to allow for catheterization and drainage of the urine.
8. The provider connects the drainage tube and catheters, sutures the site, and closes the wound in layers.

4. Qualifying circumstances

CPT 51596 is performed on patients who require a complete cystectomy with continent diversion. This procedure is commonly done for patients with bladder cancer that has spread to multiple areas of the bladder or for recurrent bladder cancer. The use of any segment of the small and/or large intestine to construct a neobladder is a key qualifying circumstance for this code.

5. When to use CPT code 51596

CPT code 51596 should be used when the provider performs a complete cystectomy with continent diversion using any open technique and any segment of the small and/or large intestine to construct a neobladder. It is important to note that this code does not include pelvic lymphadenectomy. If a pelvic lymphadenectomy is performed in addition to the cystectomy, it should be reported separately using the appropriate code.

6. Documentation requirements

To support a claim for CPT 51596, the provider must document the following information:

• Patient’s diagnosis necessitating the complete cystectomy with continent diversion
• Details of the procedure, including the use of any segment of the small and/or large intestine to construct the neobladder
• Date of the procedure
• Specific anatomical structures removed, such as the bladder, uterus, ovaries, fallopian tubes, prostate, seminal vesicles, and vas deferens
• Method used to reroute the flow of urine out of the body, such as the creation of a continent catheterizable stoma
• Details of the closure of the wound
• Signature of the provider

7. Billing guidelines

When billing for CPT 51596, ensure that the procedure meets the criteria for a complete cystectomy with continent diversion using any open technique and any segment of the small and/or large intestine to construct a neobladder. It is important to note that if a pelvic lymphadenectomy is performed in addition to the cystectomy, it should be reported separately using the appropriate code. Append modifier 50 if a bilateral lymphadenectomy is performed.

8. Historical information

CPT 51596 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2002, with an updated description. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient undergoes a complete cystectomy with continent diversion using a segment of the small intestine to construct a neobladder.
2. A provider performs a cystectomy with continent diversion for a patient with recurrent bladder cancer, using a segment of the large intestine to construct a neobladder.
3. A complete cystectomy with continent diversion is performed on a patient with bladder cancer found in multiple areas of the bladder, using a segment of the small and large intestine to construct a neobladder.
4. A provider performs a cystectomy with continent diversion using a segment of the small intestine to construct a neobladder for a patient with bladder cancer and involvement of the prostate.
5. A patient undergoes a complete cystectomy with continent diversion using a segment of the large intestine to construct a neobladder due to recurrent bladder cancer.
6. A provider performs a cystectomy with continent diversion using a segment of the small and large intestine to construct a neobladder for a patient with bladder cancer and involvement of the uterus and fallopian tubes.