toria11
Guru
The doctor would like to bill 52214 and 52310 for the service described below, but I'm not sure it would be appropriate. I know the 52310 is bundled and cannot be billed. Would the biopsy be included in 52214? Thanks!!
PROCEDURE PERFORMED:
1. Cystoscopy with extraction of bladder calculus.
2. Bladder biopsy with fulguration of biopsy site and biopsy lesion (medium size).
PREOPERATIVE DIAGNOSIS:
1. Severe irritative voiding symptoms.
2. Bladder calculus.
POSTOPERATIVE DIAGNOSIS:
1. Severe irritative voiding symptoms.
2. Bladder calculus.
DESCRIPTION OF PROCEDURE:
After successful induction of anesthesia, the patient was placed in the lithotomy position. Her perineum was sterilely prepped and draped. A #21 scope was placed in the meatus and passed proximally towards the bladder. The urethra was normal. The trigone was normal. Inspection of the bladder showed an 8 to 9 mm spear-like calculus in the posterior wall. Inspection of the rest of the bladder showed marked edema with multiple superficial ulcers and hemorrhagic regions potentially consistent with interstitial cystitis. Using the biopsy forceps, the stone was extracted first. Then, attention turned towards the lesions. The lesions were extremely friable and bled very easily. Approximately 20% of the bladder mucosa was involved with these lesions and the largest measuring approximately 4 cm in diameter posteriorly. Again, they appeared to be ulcerative and extremely hemorrhagic. Using the cold cup biopsy forceps, a biopsy was taken of 1 of these lesions to make sure she did not have carcinoma in situ or urothelial carcinoma. Next, the rollerball was used to fulgurate the biopsy site. However, since she was having significant bleeding from most of the bladder due to these lesions, each of the bleeding points were also fulgurated using the roller electrode. At the end of the procedure, there appeared to be no evidence of active bleeding. There was no evidence of perforation. The scope was then removed
and a 3-way Foley catheter inserted with ease. The effluent was clear and the patient was taken to the recovery room in good condition having tolerated the procedure well.
PROCEDURE PERFORMED:
1. Cystoscopy with extraction of bladder calculus.
2. Bladder biopsy with fulguration of biopsy site and biopsy lesion (medium size).
PREOPERATIVE DIAGNOSIS:
1. Severe irritative voiding symptoms.
2. Bladder calculus.
POSTOPERATIVE DIAGNOSIS:
1. Severe irritative voiding symptoms.
2. Bladder calculus.
DESCRIPTION OF PROCEDURE:
After successful induction of anesthesia, the patient was placed in the lithotomy position. Her perineum was sterilely prepped and draped. A #21 scope was placed in the meatus and passed proximally towards the bladder. The urethra was normal. The trigone was normal. Inspection of the bladder showed an 8 to 9 mm spear-like calculus in the posterior wall. Inspection of the rest of the bladder showed marked edema with multiple superficial ulcers and hemorrhagic regions potentially consistent with interstitial cystitis. Using the biopsy forceps, the stone was extracted first. Then, attention turned towards the lesions. The lesions were extremely friable and bled very easily. Approximately 20% of the bladder mucosa was involved with these lesions and the largest measuring approximately 4 cm in diameter posteriorly. Again, they appeared to be ulcerative and extremely hemorrhagic. Using the cold cup biopsy forceps, a biopsy was taken of 1 of these lesions to make sure she did not have carcinoma in situ or urothelial carcinoma. Next, the rollerball was used to fulgurate the biopsy site. However, since she was having significant bleeding from most of the bladder due to these lesions, each of the bleeding points were also fulgurated using the roller electrode. At the end of the procedure, there appeared to be no evidence of active bleeding. There was no evidence of perforation. The scope was then removed
and a 3-way Foley catheter inserted with ease. The effluent was clear and the patient was taken to the recovery room in good condition having tolerated the procedure well.