JenLawson
Networker
Does anyone know what circumstances/documentation will allow these two to be billed together? Encoder pro indicates that it is allowed with an appropriate modifier.
The particular situation I am looking at is:
The ureteral orifices were normal in location. This bladder tumor was superior-lateral to
the right ureteral orifice. It appeared to be low grade in appearance and frondular. The area of the tumor was about 2.5 to 3 cm. I used a loop and resected this down to the muscle. The base was then cauterized. This tumor did not look very invasive and was right on top of the right ureteral orifice. I observed the area of resection and I saw efflux of clear urine before concluding. The tumor was evacuated from the bladder and refilling the bladder showed that hemostasis was good. The total cauterized area was about 3 cm. I then emptied the bladder and put in 2% intraviscous lidocaine. I then placed a 16-French Foley catheter and then I put in 40 mg of mitomycin-C mixed in 40 mL. This will be left indwelling in the bladder for about an hour before it is removed. The patient tolerated the procedure very well. There were no complications.
Thank you!
The particular situation I am looking at is:
The ureteral orifices were normal in location. This bladder tumor was superior-lateral to
the right ureteral orifice. It appeared to be low grade in appearance and frondular. The area of the tumor was about 2.5 to 3 cm. I used a loop and resected this down to the muscle. The base was then cauterized. This tumor did not look very invasive and was right on top of the right ureteral orifice. I observed the area of resection and I saw efflux of clear urine before concluding. The tumor was evacuated from the bladder and refilling the bladder showed that hemostasis was good. The total cauterized area was about 3 cm. I then emptied the bladder and put in 2% intraviscous lidocaine. I then placed a 16-French Foley catheter and then I put in 40 mg of mitomycin-C mixed in 40 mL. This will be left indwelling in the bladder for about an hour before it is removed. The patient tolerated the procedure very well. There were no complications.
Thank you!