Liz2013
Contributor
Our outside vendor bill this with CPT 52235 but I feel it is not billed correctly. Can someone please advise? Thank you
"INDICATIONS: A 56-year-old male with history of superficial bladder cancer, for surveillance cystoscopy. Risks of bleeding and infection were explained.
OPERATIVE FINDINGS: Bulbar urethral stricture calibrated to 14-French, dilated with Goodwin sounds to 24-French. Prostatic urethra shows mild occlusion. Bladder with numerous tumors, over 30, all appear papillary. They are ranging in size between 8 mm to 2 mm. There is a small papillary tumor noted in the junction of the bladder neck and prostatic urethra at the 3 o'clock position. Total aggregate tumor is over 6 cm. The tumor at the bladder neck is 1 cm. The ureteral orifices are intact at the end of the procedure.
DESCRIPTION OF PROCEDURE: After general anesthesia was administered, with the patient in lithotomy position, genitalia prepped and draped in sterile fashion, cystoscopy was performed with a 22-French cystoscope with a 30 degree lens. The bulbar urethral stricture was intubated with a Sensor wire and the scope was used to dilate the stricture, and the bladder was inspected.
Cold cup forceps was used to biopsy representative tumor with deep specimen obtained. The base of the site was fulgurated using Bugbee electrode.
The cystoscope was then removed and Goodwin dilators were used to dilate to 24-French over the wire. Using a visual obturator the resectoscope was then passed. Bipolar current, normal saline irrigation, multiple tumors were cold looped and/or resected to their bases. The tumor at the bladder neck was resected in similar fashion.
Final inspection revealed no residual tumor. Good hemostasis was noted. Ureteral orifices were intact. Ellik evacuator was used to evacuate any specimen."
"INDICATIONS: A 56-year-old male with history of superficial bladder cancer, for surveillance cystoscopy. Risks of bleeding and infection were explained.
OPERATIVE FINDINGS: Bulbar urethral stricture calibrated to 14-French, dilated with Goodwin sounds to 24-French. Prostatic urethra shows mild occlusion. Bladder with numerous tumors, over 30, all appear papillary. They are ranging in size between 8 mm to 2 mm. There is a small papillary tumor noted in the junction of the bladder neck and prostatic urethra at the 3 o'clock position. Total aggregate tumor is over 6 cm. The tumor at the bladder neck is 1 cm. The ureteral orifices are intact at the end of the procedure.
DESCRIPTION OF PROCEDURE: After general anesthesia was administered, with the patient in lithotomy position, genitalia prepped and draped in sterile fashion, cystoscopy was performed with a 22-French cystoscope with a 30 degree lens. The bulbar urethral stricture was intubated with a Sensor wire and the scope was used to dilate the stricture, and the bladder was inspected.
Cold cup forceps was used to biopsy representative tumor with deep specimen obtained. The base of the site was fulgurated using Bugbee electrode.
The cystoscope was then removed and Goodwin dilators were used to dilate to 24-French over the wire. Using a visual obturator the resectoscope was then passed. Bipolar current, normal saline irrigation, multiple tumors were cold looped and/or resected to their bases. The tumor at the bladder neck was resected in similar fashion.
Final inspection revealed no residual tumor. Good hemostasis was noted. Ureteral orifices were intact. Ellik evacuator was used to evacuate any specimen."