# Really Stumped on How To Code This



## kathy a (Nov 29, 2013)

I am really stumped on how to code this. I cant seem to find the proper CPT code. I would really appreciated an experienced coders help on this. Here is the OP report.

Preoperative Diagnosis: Presumed seminal vesicle mass.
Postoperative: Likely rectal tumor.
Procedure: Transrectal sonography and biopsy of mass.

Indications for procedure: patient was seen in office recently with complaints of pelvic pain and a CT scan depicted a mass coming off the left seminal vesicle.

Patient was brought into the operating room and given clindamycin and gentamycin. He was given IV sedation and left lateral on the bed. Digital rectal examination revealed a normal prostate and proximal to the prostate , on the patients left side, obvious deformity of the rectal mucosa with polyp and mass. Transrectal ultrasound was performed. The prostate looked unremarkable. Coming off the tip of the seminal vesicle on the patients left is this mass. It is hard to tell if this is continuous to the rectal vault or the seminal vesicle. neverless it was biosied 5 times with a biopsy gun. A different physician came into the operating room, agreed that this was likely a rectal cancer. 

I know that the Transrectal Ultrasound is # 76872-26. The final diagnosis ended up being a Neuro-endocrine tumor and the physician said the diagnosis was 209.60.

I have looked under Biopsy rectal mucosa with a biopsy gun, Biopsy of abdominal or pelvic mass by biopsy gun. There aren't any procedure codes for these-due to the approach. With this OR note I can't seem to find what procedure code I need.
There aren't any procedures that match this surgery. I didn't know if I should go with an unlisted procedure? Any help would be greatly appreciated. Thanks!   Kathy Albert


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## Squiabro (Nov 29, 2013)

*Limited Options*

I coded this op report to 45100.


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## kathy a (Dec 2, 2013)

Thanks for your help. That was one of my codes that I had on a short list.


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