toria11
Guru
Hi! This patient underwent a repeat bladder biopsy due to abnormal scans, my question is whether the fulguration is billable in this case? It seems to me like the biopsy site was fulgurated for hemostasis since there was no apparent lesion of the bladder. Am I correct on this? If so, I would code this as 52204, 52332-50, 74420-26. Thanks for your help!
POSTOPERATIVE DIAGNOSES: 1. Bilateral hydronephrosis.
2. High-grade T1 urothelial carcinoma with
abnormal PET scan and CT scan
demonstrating thickened anterior bladder
wall suspicious for recurrent disease.
3. Prior negative bladder biopsies
transurethrally and percutaneously.
4. Severely trabeculated contracted bladder
with no papillary tumors or abnormal
urothelium.
PROCEDURES PERFORMED: Cystoscopy, bilateral ureteral stent placement,
right retrograde pyelogram, and bladder biopsies
with fulguration (3 cm).
ANESTHESIA: General.
COMPLICATIONS: None.
PATHOLOGY: Bladder biopsies.
FINDINGS: Right retrograde pyelogram revealed tortuous ureter. A 6-French x 24 cm double-J stent
was placed in adequate position bilaterally to exchange the indwelling stents, which had been placed in
antegrade fashion.
Bladder was heavily trabeculated with no evidence of abnormal urothelium other than inflammation around
the left ureteral orifice from the stent. Bladder biopsies were taken along the anterior wall and junction of
the right lateral along the anterior wall with the traditional electrosurgical loop. Biopsy areas were
fulgurated. Hemostasis was excellent. The bladder was not perforated.
DETAILS OF PROCEDURE: The patient was taken to the operating room and positively identified as
well as the site of surgery during a time-out. After adequate general anesthesia, he was transferred into
the modified dorsal lithotomy position and prepped and draped in usual sterile fashion for cystoscopy. The
22-French cystoscope sheath was passed with the obturator in place. The Foroblique lens was then
inserted and careful panendoscopy was performed. The bladder was heavily trabeculated without any
obvious tumor, stones, or abnormal urothelium other than adjacent to the left ureteral orifice. Inflammation
was consistent with stent irritation. The right stent was grasped with forceps and drawn out through the
urethral meatus. A guidewire was passed under fluoroscopic guidance. The guidewire was then
backloaded through the cystoscope and a 6-French x 24 cm double-J stent placed in standard fashion.
There was loop in the stent concerning for an appropriate positioning. Therefore, the stent was removed
and open ended catheter was passed over the guidewire. Retrograde pyelogram was then performed
confirming tortuosity of the ureter. The ureter was able to be straightened and the guidewire replaced. A
double-J stent was then placed again in standard fashion. The guidewire was removed, and had an
excellent lie. This was repeated on left-hand side without difficulty. A retrograde pyelogram was not
required on left-hand side. Both stents appeared to be in excellent position.
Urethral meatus was then dilated up to 30-French with van Buren sounds to allow passage of the
26-French continuous flow resectoscope sheath which was passed with the visual obturator. Biopsies
were taken with the traditional electrosurgical loop in the anterior wall and junction of the right lateral wall
and anterior wall. These appeared to reach superficial muscle. Muscle appeared to be normal in
appearance. Biopsy site spanned approximately 3 cm, which was fulgurated. Hemostasis was excellent.
There was no evidence bladder perforation. Bladder was left partially distended and the scope was
removed. An 18-French Foley catheter was placed over the catheter guide and the balloon was inflated to
10 cc. The catheter was irrigated freely and the effluent came back crystal clear. He tolerated the
procedure well without complications. EB 20211216
POSTOPERATIVE DIAGNOSES: 1. Bilateral hydronephrosis.
2. High-grade T1 urothelial carcinoma with
abnormal PET scan and CT scan
demonstrating thickened anterior bladder
wall suspicious for recurrent disease.
3. Prior negative bladder biopsies
transurethrally and percutaneously.
4. Severely trabeculated contracted bladder
with no papillary tumors or abnormal
urothelium.
PROCEDURES PERFORMED: Cystoscopy, bilateral ureteral stent placement,
right retrograde pyelogram, and bladder biopsies
with fulguration (3 cm).
ANESTHESIA: General.
COMPLICATIONS: None.
PATHOLOGY: Bladder biopsies.
FINDINGS: Right retrograde pyelogram revealed tortuous ureter. A 6-French x 24 cm double-J stent
was placed in adequate position bilaterally to exchange the indwelling stents, which had been placed in
antegrade fashion.
Bladder was heavily trabeculated with no evidence of abnormal urothelium other than inflammation around
the left ureteral orifice from the stent. Bladder biopsies were taken along the anterior wall and junction of
the right lateral along the anterior wall with the traditional electrosurgical loop. Biopsy areas were
fulgurated. Hemostasis was excellent. The bladder was not perforated.
DETAILS OF PROCEDURE: The patient was taken to the operating room and positively identified as
well as the site of surgery during a time-out. After adequate general anesthesia, he was transferred into
the modified dorsal lithotomy position and prepped and draped in usual sterile fashion for cystoscopy. The
22-French cystoscope sheath was passed with the obturator in place. The Foroblique lens was then
inserted and careful panendoscopy was performed. The bladder was heavily trabeculated without any
obvious tumor, stones, or abnormal urothelium other than adjacent to the left ureteral orifice. Inflammation
was consistent with stent irritation. The right stent was grasped with forceps and drawn out through the
urethral meatus. A guidewire was passed under fluoroscopic guidance. The guidewire was then
backloaded through the cystoscope and a 6-French x 24 cm double-J stent placed in standard fashion.
There was loop in the stent concerning for an appropriate positioning. Therefore, the stent was removed
and open ended catheter was passed over the guidewire. Retrograde pyelogram was then performed
confirming tortuosity of the ureter. The ureter was able to be straightened and the guidewire replaced. A
double-J stent was then placed again in standard fashion. The guidewire was removed, and had an
excellent lie. This was repeated on left-hand side without difficulty. A retrograde pyelogram was not
required on left-hand side. Both stents appeared to be in excellent position.
Urethral meatus was then dilated up to 30-French with van Buren sounds to allow passage of the
26-French continuous flow resectoscope sheath which was passed with the visual obturator. Biopsies
were taken with the traditional electrosurgical loop in the anterior wall and junction of the right lateral wall
and anterior wall. These appeared to reach superficial muscle. Muscle appeared to be normal in
appearance. Biopsy site spanned approximately 3 cm, which was fulgurated. Hemostasis was excellent.
There was no evidence bladder perforation. Bladder was left partially distended and the scope was
removed. An 18-French Foley catheter was placed over the catheter guide and the balloon was inflated to
10 cc. The catheter was irrigated freely and the effluent came back crystal clear. He tolerated the
procedure well without complications. EB 20211216