Summary & Overview
HCPCS G9631: Ureter Injury During or Within 30 Days After Surgery
HCPCS Level II code G9631 designates a ureter injury sustained during surgery or identified within 30 days after surgery. As a complication code tied to perioperative care, it is relevant to hospitals, surgical centers, and payers for documenting adverse events and post-operative management. Accurate coding of ureteral injuries affects quality reporting, complication tracking, and claims adjudication across the care continuum.
Key payers included in this analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The code’s use may influence case reviews, readmission assessments, and surgical quality metrics that payers monitor nationally.
Readers will find a concise overview of clinical context and typical sites of service, plus a review of payer considerations, common modifiers, and related documentation needs. The publication covers benchmark considerations and policy-relevant aspects such as complication reporting and claims processing practices. Where specific data elements were not provided in the input, the publication indicates “Data not available in the input.” The focus is national in scope and intended for coding professionals, revenue cycle staff, and clinical leaders seeking a clear summary of HCPCS Level II code G9631 and its relevance in surgical complication documentation.
Billing Code Overview
HCPCS Level II code G9631 indicates that a patient sustained a ureter injury at the time of surgery or that the injury was discovered subsequently within 30 days post-surgery. This code documents a surgical complication related to the ureter.
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Service type: Surgical complication identification and related medical management
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Typical site of service: Inpatient or outpatient surgical settings, including operating room, post-anesthesia care unit, and hospital observation or inpatient stays
Data not available in the input.
Clinical & Coding Specifications
Clinical Context
A 52-year-old woman undergoes elective total abdominal hysterectomy for symptomatic uterine fibroids at an ambulatory surgery center. During the procedure, the surgeon suspects a thermal injury to the left ureter after hemostasis is achieved. Intraoperative cystoscopy and retrograde pyelogram are performed; contrast extravasation confirms a ureteral transection. The operative team proceeds with ureteral reimplantation (ureteroneocystostomy) under the same anesthetic. The patient is admitted to the hospital for postoperative monitoring and receives a ureteral stent. Alternatively, a patient may present within 30 days after a pelvic operation with flank pain, fever, or rising creatinine; imaging (CT urogram or IVP) identifies a delayed ureteral injury requiring interventional radiology drainage, ureteral stenting, or return to the operating room for repair. Typical workflow includes identification of injury, diagnostic imaging (cystoscopy, retrograde pyelogram, CT urogram), stabilization, temporary urinary diversion or stenting, and definitive surgical repair as indicated.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work required is substantially greater than typically required for the procedure due to extensive repair or unexpected complexity from the ureteral injury. |