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Urology Coding Alert

You Be the Coder:

Is a 2-Days-Post-Op Return to OR Billable?

Published on Sun Nov 18, 2012

Question: We had a patient who was two days post op from a TURBNC (52500). The patient had to go back to the OR, and the urologist's documentation states:"Then using the Olympus 26-French resectoscope sheath with the Schmidt obturator, visual urethroscopy was carried out. The distal urethra was open and clear. The verumontanum was intact. The prostatic fossa had blood clots and debris within it. The bladder neck had an adherent blood clot. The bladder was filled with blood clots.  After passage of the instrument a Toomey syringe was used to evacuate the blood clots. Then the Iglesias resectoscope was inserted. Bleeding was noted to be coming from the area of the bladder neck at around the 6 o'clock position and another area around the 11 o'clock position. Using the resectoscope, these areas were resected and their bases re-cauterized. The bladder was cleared and freed of all tissue debris and clot. There was no further bleeding [...]
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