Could someone please help with coding suggestion for the following case?
"
PREPROCEDURE DIAGNOSIS: Hematuria
POSTPROCEDURE DIAGNOSIS: Bladder tumor.
PROCEDURE PERFORMED: Transurethral resection of bladder tumor ( medium). Vaginal
exam
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS GIVEN: Crystalloid.
DRAINS PLACED: 16-French 10cc bladder catheter.
SPECIMENS: Bladder mass and biopsy of back wall
COMPLICATIONS: None.
INDICATIONS: This is a 48-year-old female with a long history of bladder related
problems. Of recent she has been treated for multiple urinary infections but
also has experienced hematuria and pain with voiding. She would not agree to
cystoscopy in the office and thus agreed to cystoscopy with addressing of any
pathology identified.
FINDINGS: The bladder trigone specifically in the center was heaped/elevated
suggestive of a external mass affect. Vaginal exam identified palpable fullness
in the anterior vagina adjacent to this visible region. Erythematous lesions on
the back wall. Resection through the apex of the mounded mass like area
uncovered efflux of a thick toothpaste like substance essentially draining a
large cyst cavity. The mucosa and walls of the cyst had superficial papillary
type and inflammatory appearing mucosa. Vaginal exam after the entire
procedure was over revealed no evidence of intrusion into the vagina mucosa and
normalization of findings.
OPERATIVE NOTE: After being given adequate anesthetic and perioperative
antibiotics, sequential compression devices were applied. She was placed in a
dorsal lithotomy position and prepped and draped in usual sterile manner. A
rigid cystourethroscope was placed transurethrally into the bladder with the
above findings noted.
A bipolar resectoscope was introduced and resection through the apex of the
mound of the mass was performed. This unroofed a cystic-like structure with
efflux of thick toothpaste-like substance. After the entire cyst was evacuated
biopsies of the wall were taken. The base was fulgurated. A monopolar
resectoscope was swapped out for the bipolar to allow for a rollerball electrode
to be introduced. This allowed for better fulguration of the walls of this
cyst like mass. Rigid forceps were used to obtain a biopsy specimen of a back
wall erythematous lesion. The rollerball was then used for hemostasis. At the
end the procedure there was no active bleeding. Bilateral ureteral orifices
were well identified. No evidence of bladder perforation. The scope was
removed and a 16 French Foley catheter was placed. Vaginal exam with a vaginal
speculum identified intact vaginal mucosa. Palpation showed complete
normalization."
"
PREPROCEDURE DIAGNOSIS: Hematuria
POSTPROCEDURE DIAGNOSIS: Bladder tumor.
PROCEDURE PERFORMED: Transurethral resection of bladder tumor ( medium). Vaginal
exam
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS GIVEN: Crystalloid.
DRAINS PLACED: 16-French 10cc bladder catheter.
SPECIMENS: Bladder mass and biopsy of back wall
COMPLICATIONS: None.
INDICATIONS: This is a 48-year-old female with a long history of bladder related
problems. Of recent she has been treated for multiple urinary infections but
also has experienced hematuria and pain with voiding. She would not agree to
cystoscopy in the office and thus agreed to cystoscopy with addressing of any
pathology identified.
FINDINGS: The bladder trigone specifically in the center was heaped/elevated
suggestive of a external mass affect. Vaginal exam identified palpable fullness
in the anterior vagina adjacent to this visible region. Erythematous lesions on
the back wall. Resection through the apex of the mounded mass like area
uncovered efflux of a thick toothpaste like substance essentially draining a
large cyst cavity. The mucosa and walls of the cyst had superficial papillary
type and inflammatory appearing mucosa. Vaginal exam after the entire
procedure was over revealed no evidence of intrusion into the vagina mucosa and
normalization of findings.
OPERATIVE NOTE: After being given adequate anesthetic and perioperative
antibiotics, sequential compression devices were applied. She was placed in a
dorsal lithotomy position and prepped and draped in usual sterile manner. A
rigid cystourethroscope was placed transurethrally into the bladder with the
above findings noted.
A bipolar resectoscope was introduced and resection through the apex of the
mound of the mass was performed. This unroofed a cystic-like structure with
efflux of thick toothpaste-like substance. After the entire cyst was evacuated
biopsies of the wall were taken. The base was fulgurated. A monopolar
resectoscope was swapped out for the bipolar to allow for a rollerball electrode
to be introduced. This allowed for better fulguration of the walls of this
cyst like mass. Rigid forceps were used to obtain a biopsy specimen of a back
wall erythematous lesion. The rollerball was then used for hemostasis. At the
end the procedure there was no active bleeding. Bilateral ureteral orifices
were well identified. No evidence of bladder perforation. The scope was
removed and a 16 French Foley catheter was placed. Vaginal exam with a vaginal
speculum identified intact vaginal mucosa. Palpation showed complete
normalization."