How would you code the following? 52204 or 52235? The site had been previously resected.
He recently underwent cystoscopy and the center of the previous resection appeared to be somewhat hyperemic now.
He had one lesion that definitely appeared superficial. I thought I could take a couple of cold cup biopsies
from this and then to cauterize the entire area that is about 3 to 5 cm long characterizing this is a
medium-sized recurrence. So, he received appropriate preoperative antibiotics in the holding area. He
was taken to the operating room, given a general anesthetic. A time-out was taken for identification
purposes. He was then placed in the dorsal lithotomy position, and a rigid scope was passed, and the area
of previous concern. With the small papillary what appeared to be a papillary recurrence, I was able to
cold cup biopsy and submit that and I took biopsies from several other areas and then with the use of the
hot loop, I cauterized the area that has been previously resected that appeared to me to be somewhat
hyperemic at the present time. He then tolerated all of that well. A Foley catheter was inserted and he
was returned to the recovery room in stable condition.
He recently underwent cystoscopy and the center of the previous resection appeared to be somewhat hyperemic now.
He had one lesion that definitely appeared superficial. I thought I could take a couple of cold cup biopsies
from this and then to cauterize the entire area that is about 3 to 5 cm long characterizing this is a
medium-sized recurrence. So, he received appropriate preoperative antibiotics in the holding area. He
was taken to the operating room, given a general anesthetic. A time-out was taken for identification
purposes. He was then placed in the dorsal lithotomy position, and a rigid scope was passed, and the area
of previous concern. With the small papillary what appeared to be a papillary recurrence, I was able to
cold cup biopsy and submit that and I took biopsies from several other areas and then with the use of the
hot loop, I cauterized the area that has been previously resected that appeared to me to be somewhat
hyperemic at the present time. He then tolerated all of that well. A Foley catheter was inserted and he
was returned to the recovery room in stable condition.