You Be the Coder:
Antegrade Cystoscopies Through Established SP Tract
Published on Sun Jul 15, 2012
Question: How should I code the following procedure:Operative note reads: "The urethrotome on a 12 degree scope was introduced into the urethra. In the mid-pendulous urethra, there was a small stricture that was incised, and easily passed with the scope. At the level of the membranous/prostatic urethra, there was a blind end, and there was not even a pinhole opening into the proximal urethra and bladder.The decision at this time was to perform antegrade cystoscopy, and attempt to "cut to the light," to see if we could find a tract into the bladder. The suprapubic tube was removed by the nursing staff and the suprapubic area was prepped and draped in a sterile fashion. A flexible cystoscope was introduced into the bladder through the suprapubic tract and the bladder was examined. There was several trabeculations. There were no masses, lesions, or stones. There was some inflammation, consistent with the patient's [...]