# New to Urology HELP!



## ASC CODER (Feb 22, 2010)

Preoperative Diagnosis Abnormal imaging on CT scan of the abdomen. 
Postoperative Diagnosis Same 
Procedure CMG w abdominal Pressure Study, EMG, UPP, Cystourethroscopy 

Anesthesia Local anesthesia with 2% lidocaine urethral jelly (Urojet) 
Operative Findings No evidence of bladder mucosal tumor grossly. 

Specimen None 
EBL None 
Complications None 

CLINICAL HISTORY gentleman was noted to have filling defect in the bladder on CT scan of the abdomen. Patient is recommended to have cystoscopic examination. 

DISCRIPTION OF THE OPERATIVE PROCEDURE:

The patient was lying down in supine position on the operating table. The genitalia, upper thighs, and abdomen were prepped and draped in sterile manner. After this, genitalia, lower abdomen, and upper thighs were prepped and draped in sterile manner.
2 % lidocaine jelly (Urojet) was instilled through the external urethral meatus, and after its adequate action for about 5 minutes, 16 French CYF5 Olympus flexible deflectable cystourethroscope was introduced through the external urethral meatus along the lumen of the urethra into the bladder. Inside of the urethra and bladder were visualized. Findings are as follows:

CYSTOURETHROSCOPIC FINDINGS:
Anterior urethra: Normal
Area of external urethral sphincter: Normal
Verumontanum: Normal. 
Posterior urethra: Elongated with enlargement of both lateral lobes and median lobe of the prostate gland.
Bladder neck: Normal.
Right ureteral orifice: Normal regarding its configuration and position with clear urinary efflux from the right ureteral orifice.
Left ureteral orifice: Normal regarding its configuration and position with clear urinary efflux from the left ureteral orifice.

All the bladder walls the dome and trigone were examined. The was no evidence of foreign body or calculus

Bladder Mucosa: Normal
Trabeculations: None
Bladder diverticula: None
Cellules: None

After this the cystoscope was withdrawn and urethral findings were reconfirmed. Patient was then brought back to supine position and was returned to the recovery room in satisfactory general condition.

IMPRESSION: 
No evidence of bladder mucosal tumor grossly.

RECOMMENDATION: 
Follow up prn.


----------



## ASC CODER (Feb 22, 2010)

I was hoping for some info on the guidlines for coding urology, Just so I know this is going out right. Please!


----------



## Kelly_Mayumi (Feb 23, 2010)

Are looking for a code for this service?  It is 52000.


----------



## ASC CODER (Feb 23, 2010)

thank you 

Just have not done urology and was unsure any tips and or sites you can give me would be helpful. 

Thanks again


----------

