I have a doctor who frequently suctions out "bladder debris" using a syringe. The patients always have a UTI, so I think he is cleaning out infection. I have a co-worker who codes this as foreign body removal, but I don't think that would be correct. If the doctor is performing a cystoscpy, then cleans out this "debris", would it be considered part of the cystoscopy procedure? How would you code the following?
ANESTHETIC: General.
PREOPERATIVE DIAGNOSIS: Chronic urinary tract infection.
POSTOPERATIVE DIAGNOSIS: Chronic urinary tract infection.
OPERATION: Cystoscopy with evacuation of bladder debris.
ESTIMATED BLOOD LOSS: Zero.
DRAIN: None.
POSTOPERATIVE CONDITION: Good.
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in the usual sterile fashion in dorsal lithotomy position. A 20-French ACMI scope was inserted into the bladder. A large amount of bladder debris was evacuated utilizing a Toomey syringe. There were no tumors, diverticulum, or calculi. Both ureteric orifices were effluxing clear urine. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.
ANESTHETIC: General.
PREOPERATIVE DIAGNOSIS: Chronic urinary tract infection.
POSTOPERATIVE DIAGNOSIS: Chronic urinary tract infection.
OPERATION: Cystoscopy with evacuation of bladder debris.
ESTIMATED BLOOD LOSS: Zero.
DRAIN: None.
POSTOPERATIVE CONDITION: Good.
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in the usual sterile fashion in dorsal lithotomy position. A 20-French ACMI scope was inserted into the bladder. A large amount of bladder debris was evacuated utilizing a Toomey syringe. There were no tumors, diverticulum, or calculi. Both ureteric orifices were effluxing clear urine. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.