I have a coding question I need help with the cpt codes thanks in advance.
Procedure Performed:
1. Urethral dilatation
2. Cystoscopy
3. Transurethral resection of the prostate
Operative Summary: The patient was brought to the operating room and placed under anesthesia without any problems. He was prepped and draped in the usual sterile fashion in the lithotomy position. Examination demonstrated urethral meatal stenosis and we dilated him with sounds up to 30 French. We then performed cystoscopy with a 22-French scope and 20 degree lens. The urethra was normal up to the prostatic urethra, which showed a large amount of lateral, anterior and even median lobe tissue. The prostatic urethra measured about 4 cm. The bladder neck was elevated as a result of long term obstruction. The bladder showed Grade 4 trabeculations with cellules, diverticula, but no evidence of bladder mass. The resectoscope was inserted and the prostate was resected in a circumferential fashion from the bladder neck down to the verumontanum. First, we resected between 5 and 7 o'clock identifying the ureteral orifices on both sides and resecting the median lobe in completion. We then resected the lateral and anterior lobe tissue. Care was taken at all times to avoid cautery or resection distal to the verumontanum, thus avoiding injury to the external urethral sphincter. Prostate chips were sent for routine pathologic evaluation. Additional homeostasis was achieved with cautery and was found to be excellent. Numerous prostatic calculi were liberated through the course of the resection and treatment. Upon completion, the 24 French three-way Foley catheter was placed that drained clear urine in the irrigant. It was left to gentle traction.
Procedure Performed:
1. Urethral dilatation
2. Cystoscopy
3. Transurethral resection of the prostate
Operative Summary: The patient was brought to the operating room and placed under anesthesia without any problems. He was prepped and draped in the usual sterile fashion in the lithotomy position. Examination demonstrated urethral meatal stenosis and we dilated him with sounds up to 30 French. We then performed cystoscopy with a 22-French scope and 20 degree lens. The urethra was normal up to the prostatic urethra, which showed a large amount of lateral, anterior and even median lobe tissue. The prostatic urethra measured about 4 cm. The bladder neck was elevated as a result of long term obstruction. The bladder showed Grade 4 trabeculations with cellules, diverticula, but no evidence of bladder mass. The resectoscope was inserted and the prostate was resected in a circumferential fashion from the bladder neck down to the verumontanum. First, we resected between 5 and 7 o'clock identifying the ureteral orifices on both sides and resecting the median lobe in completion. We then resected the lateral and anterior lobe tissue. Care was taken at all times to avoid cautery or resection distal to the verumontanum, thus avoiding injury to the external urethral sphincter. Prostate chips were sent for routine pathologic evaluation. Additional homeostasis was achieved with cautery and was found to be excellent. Numerous prostatic calculi were liberated through the course of the resection and treatment. Upon completion, the 24 French three-way Foley catheter was placed that drained clear urine in the irrigant. It was left to gentle traction.