The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Laparoscopic augmentation cystoplasty (including clam cystoplasty).
An ‘overactive bladder’ or detrusor hyper-reflexia causes symptoms of urgent need to urinate, urge incontinence, frequent urination and waking at night to urinate. One of the causes is bladder muscle (detrusor) overactivity, in which the detrusor contracts unexpectedly during bladder filling. Laparoscopic augmentation cystoplasty (including clam cystoplasty) is reconstructive surgery to increase the size of the bladder and is done via small incisions. The procedure involves sewing or stapling a tissue graft from a section of the small intestine (ileum), colon or other substitutes to the urinary bladder.
A code from the following OPCS-4 category is selected depending on the area of the intestine used for the graft:
M36.- Enlargement of bladder
OPCS-4 code Y75.2 Laparoscopic approach to abdominal cavity NEC is assigned following one of the above codes to identify the laparoscopic approach.
Note: If during the procedure there was also creation of a urinary diversion (Mitrofanoff) stoma; this would require coding in addition.
The NHS Classifications Service of NHS Connecting for Health is the central definitive source for clinical coding guidance and determines the coding standards associated with the classifications (OPCS-4 and ICD-10) to be used across the NHS. The NHS Classifications Service and NICE work collaboratively to ensure the most appropriate classification codes are provided. www.connectingforhealth.co.uk/clinicalcoding