Wiki 51102 or 51040?

[toria11]

Would this be coded as 51102? I'm questioning whether 51040 would be more appropriate because he did "cut down" to the instrument through muscle, fascia, etc. under general anesthesia. Thanks!!

Procedure Performed
Suprapubic cystostomy tube placement

Type of Anesthesia
General

Indications
Neurogenic bladder

Technique/Description of Procedure
Patient was placed in the dorsal lithotomy position prepped and draped in the usual manner his bladder was distended with saline. We then passed the Lowsley retractor into the bladder. It was tented up against the abdominal wall. We then cut down on it until the instrument came through the wound. Once this was done we grasped a 22 Foley and it was brought into the bladder. We then passed the cystoscope into the urethra and positioned the catheter under direct vision. The balloon was inflated with 30 cc of saline it irrigated clearly. We then secured the catheters to the abdominal wall with a 0 silk. Dressing applied and he was transferred recovery in stable condition

Implants and Devices
Suprapubic cystostomy tube

Estimated Blood Loss
None

Patient Condition/Disposition
Condition stable transferred recovery room and to medical-surgical floor

 

[liqgold2@aol.com]

Since all layers of the abdomen and the bladder wall were incised, I would suggest 51040 as the correct code. Cystoscopy may be billed with 52000, but a more detailed documentation of the cystoscopy would be in order.