Wiki 52601 or 52500?

[umcanes4]

Hey!! Hoping someone can help with this. We have different views on the codes for this procedure. We agree on the codes for the Urolift and the Cystolitholapaxy. It's the Trans urethral resection of bladder neck median bar
procedure where we have a difference of codes.

Would this be a 52601 or 52500?

Procedure Name:
Elective Cystolitholapaxy (2-3cm stone x 2)
Trans urethral resection of bladder neck median bar
Urolift procedure.


Procedure Description:
Pt was taken to the OR, induced under general anesthesia, positioned in dorsal lithotomy, and prepped & draped in standard surgical fashion. Cystoscopy was performed that revealed bilateral mild lobar prostatic hyperplasia and a high median bladder neck. Two 2-3cm bladder stones were seen. At this time, cystolitholapaxy was performed using the holmium laser. The bladder stone was fragmented into very small fragments. The stone fragments were washed out and sent for stone analysis.

Trans-urethral resection of the bladder neck median bar was then performed using the bipolar resectoscope to create a nice open channel. The prostatic chips were washed out & sent to pathology for permanent exam. At this time the urolift scope was inserted and the urolift device deployed 4 times: one on each side of the prostate 1-2 cm proximal to the bladder neck, 1 on each side of the lateral lobes just distal to the verumontanum. A nice open channel was created from the verumontanum to the bladder neck. The bladder was partially filled and then the scope removed. A 20F/10cc foley was placed and was draining clear urine.

PATH:
BLADDER NECK, RESECTION:
BENIGN PROSTATE TISSUE AND BLADDER MUCOSA.
NO DYSPLASIA OR MALIGNANCY IDENTIFIED.


Thanks for the help. It's appreciated

 

[emcee101]

It sounds like a TURBN (52500) was done as part of a TURP (52601). I would double check with your doctor but from the anatomic locations listed "from the verumontanum to the bladder neck" it seems to me that a larger area than just the bladder neck was resected since the verumontanum is part of the prostatic urethra and not the bladder neck.