Having some confusion on went to be able to code these separately, provider wants me to bill them together with 52283-59, but I don't think the documentation is sufficient to bill separately or is it? HELP!
OP REPORT:
PREOPERATIVE DIAGNOSIS: Pre-Op Diagnosis Codes:
* Bladder neck contracture [N32.0]
* Benign prostatic hyperplasia (BPH) with urinary urge incontinence [N40.1, N39.41]
POSTOPERATIVE DIAGNOSIS: Post-Op Diagnosis Codes:
* Bladder neck contracture [N32.0]
* Benign prostatic hyperplasia (BPH) with urinary urge incontinence [N40.1, N39.41]
PROCEDURE/SURGERY: Transurethral incision of bladder neck contracture and injection of steroids
SURGEON: Surgeon(s):
XXX
ANESTHESIOLOGIST: XXXX
ANESTHESIA TYPE: General
ESTIMATED BLOOD LOSS: 5 ml
COMPLICATIONS: None
FINDINGS: Dense bladder neck contracture
SPECIMENS: None
INDICATIONS FOR SURGERY: This is a 79 year old male with BPH s/p TUVP on 3/24/17. He has developed a bladder neck contracture. Treatment options were discussed, and the patient has opted to proceed with today's procedure. Risks and benefits were discussed, and a consent form was signed.
SUMMARY OF PROCEDURE:
The patient was brought in the OR and placed in the dorsal lithotomy position. Following anesthesia, he was then prepped and draped in the standard surgical fashion. A rigid resectoscope sheath with 30 degrees lens and visual obdurator was placed into the urethra. A moderate bladder neck contracture was noted at the bladder neck. The resectoscope sheath could not be passed through the contracted area. A Collins cold knife was then placed onto a resectoscope and placed through the sheath. The strictured tissue was then incised at 3, 5, 7, 8 oclock positions to open up the contracture fully and allow easy passage of the 27 Fr resectoscope sheath. Inspection of the bladder inside demonstrated no abnormalities. Mild bleeding was noted. The sheath was removed, and a 23 Fr rigid cystoscope was placed into the urethra. A long flexible needle was passed through the cystoscopy until the needle was visible in the lumen. The incised areas were then injected with Kenalog steroid all around the bladder neck. A total of 40 mg of steroid was injected into the tissue. The cystoscope was removed, and an 22 Fr 2-way catheter was then placed into the bladder. 30 ml of sterile water was placed into the balloon to retain it there, and the bladder was emptied. The catheter was connected to a leg bag. The case was then completed. The patient tolerated the procedure well.
OP REPORT:
PREOPERATIVE DIAGNOSIS: Pre-Op Diagnosis Codes:
* Bladder neck contracture [N32.0]
* Benign prostatic hyperplasia (BPH) with urinary urge incontinence [N40.1, N39.41]
POSTOPERATIVE DIAGNOSIS: Post-Op Diagnosis Codes:
* Bladder neck contracture [N32.0]
* Benign prostatic hyperplasia (BPH) with urinary urge incontinence [N40.1, N39.41]
PROCEDURE/SURGERY: Transurethral incision of bladder neck contracture and injection of steroids
SURGEON: Surgeon(s):
XXX
ANESTHESIOLOGIST: XXXX
ANESTHESIA TYPE: General
ESTIMATED BLOOD LOSS: 5 ml
COMPLICATIONS: None
FINDINGS: Dense bladder neck contracture
SPECIMENS: None
INDICATIONS FOR SURGERY: This is a 79 year old male with BPH s/p TUVP on 3/24/17. He has developed a bladder neck contracture. Treatment options were discussed, and the patient has opted to proceed with today's procedure. Risks and benefits were discussed, and a consent form was signed.
SUMMARY OF PROCEDURE:
The patient was brought in the OR and placed in the dorsal lithotomy position. Following anesthesia, he was then prepped and draped in the standard surgical fashion. A rigid resectoscope sheath with 30 degrees lens and visual obdurator was placed into the urethra. A moderate bladder neck contracture was noted at the bladder neck. The resectoscope sheath could not be passed through the contracted area. A Collins cold knife was then placed onto a resectoscope and placed through the sheath. The strictured tissue was then incised at 3, 5, 7, 8 oclock positions to open up the contracture fully and allow easy passage of the 27 Fr resectoscope sheath. Inspection of the bladder inside demonstrated no abnormalities. Mild bleeding was noted. The sheath was removed, and a 23 Fr rigid cystoscope was placed into the urethra. A long flexible needle was passed through the cystoscopy until the needle was visible in the lumen. The incised areas were then injected with Kenalog steroid all around the bladder neck. A total of 40 mg of steroid was injected into the tissue. The cystoscope was removed, and an 22 Fr 2-way catheter was then placed into the bladder. 30 ml of sterile water was placed into the balloon to retain it there, and the bladder was emptied. The catheter was connected to a leg bag. The case was then completed. The patient tolerated the procedure well.