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.
This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.