khagt28
New
Pt. came with BPH and hematuria. On the operative note states:
TITLE OF PROCEDURES:
1. Cystoscopy.
2. Transurethral resection of the prostate.
3. Cystoscopy with bladder biopsy.
A transurethral resection of the prostate then took place using a saline
resectoscope. Initially, the median bar was taken down from the 5 o'clock
to 7 o'clock position from the bladder neck up to the level of the
verumontanum. The lateral lobes were then taken down from the 11 o'clock
to 7 o'clock position and the 1 o'clock to the 4 o'clock position from the
bladder neck up to the level of the verumontanum. The apical tissue was
then resected. The anterior tissue was then resected. At this point, he
had a wide open prostatic urethral channel. All bleeding sites were
cauterized.
An Ellik was then used to evacuate all the prostatic chips. The
resectoscope was then used to perform a bladder biopsy the posterior upper
wall of the bladder that had to be petechial erythematous areas. This was
sent in a separate container to pathology for further evaluation. The
biopsy site was then fulgurated. The bladder was then copiously irrigated.
There was no evidence of any active bleeding from the biopsy sites.
The Surgical pathology states:
SPECIMEN:
A. PROSTATE CHIPS, LESION
B. BLADDER BIOPSY, POSTERIOR
A. Received in formalin labeled "prostate tissue" are multiple
irregular and resilient fragments of tan-pink soft tissue, measuring
8.0 x 3.0 x 1.0 cm in aggregate. The specimen weighs 8 grams. The
specimen is entirely submitted in ten cassettes.
B. Received in formalin labeled "posterior bladder biopsy" are three
hemorrhagic fragments of tan-pink soft tissue, ranging from 0.2 cm to
0.4 cm. The specimen is entirely submitted in one cassette.
-------------------------------------------
The provider only coded 52234. It was denied and replaced with 52224.
I was thinking, should there be separate codes for biopsy of bladder and biopsy of prostate? Should there be a different code for TURP? or is it captured in the 52224 code?
TITLE OF PROCEDURES:
1. Cystoscopy.
2. Transurethral resection of the prostate.
3. Cystoscopy with bladder biopsy.
A transurethral resection of the prostate then took place using a saline
resectoscope. Initially, the median bar was taken down from the 5 o'clock
to 7 o'clock position from the bladder neck up to the level of the
verumontanum. The lateral lobes were then taken down from the 11 o'clock
to 7 o'clock position and the 1 o'clock to the 4 o'clock position from the
bladder neck up to the level of the verumontanum. The apical tissue was
then resected. The anterior tissue was then resected. At this point, he
had a wide open prostatic urethral channel. All bleeding sites were
cauterized.
An Ellik was then used to evacuate all the prostatic chips. The
resectoscope was then used to perform a bladder biopsy the posterior upper
wall of the bladder that had to be petechial erythematous areas. This was
sent in a separate container to pathology for further evaluation. The
biopsy site was then fulgurated. The bladder was then copiously irrigated.
There was no evidence of any active bleeding from the biopsy sites.
The Surgical pathology states:
SPECIMEN:
A. PROSTATE CHIPS, LESION
B. BLADDER BIOPSY, POSTERIOR
A. Received in formalin labeled "prostate tissue" are multiple
irregular and resilient fragments of tan-pink soft tissue, measuring
8.0 x 3.0 x 1.0 cm in aggregate. The specimen weighs 8 grams. The
specimen is entirely submitted in ten cassettes.
B. Received in formalin labeled "posterior bladder biopsy" are three
hemorrhagic fragments of tan-pink soft tissue, ranging from 0.2 cm to
0.4 cm. The specimen is entirely submitted in one cassette.
-------------------------------------------
The provider only coded 52234. It was denied and replaced with 52224.
I was thinking, should there be separate codes for biopsy of bladder and biopsy of prostate? Should there be a different code for TURP? or is it captured in the 52224 code?