Kathryn M. Foss
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Please advise if the following procedure should be reported with procedure code 52204 or something else.
Patient was brought to the operating suite, placed in the lithotomy position, prepped and draped in the usual sterile fashion. After adequate general anesthesia was obtained, Ancef was given preoperatively. The cystoscope was inserted per urethra after a time-out was performed. The urethra was normal. Prostatic lobes were seen and enlarged. There was a median lobe kind of pointing over a little bit to his right side. Bilateral ureteral orifices were normal. Bladder was normal, but there was a cystic lesion that was anterior, but if you followed it, it actually seemed to attach more laterally on the left prostatic lobe bladder neck area extending into the bladder. Went ahead and did some biopsies of it with just a cold cup and sent it off separately to Pathology and then used the loop to resect the area on the prostate without any difficulty. Ellik was used to remove the chips. Hemostasis was excellent. The chips were sent separately as a specimen too of that prostatic mass area on the left lobe. At the end of the procedure, there were no specimens. The bladder was clear. Went ahead and left some fluid in and removed the cystoscope. A Foley catheter was placed without any difficulty and was put to drainage.
Patient was brought to the operating suite, placed in the lithotomy position, prepped and draped in the usual sterile fashion. After adequate general anesthesia was obtained, Ancef was given preoperatively. The cystoscope was inserted per urethra after a time-out was performed. The urethra was normal. Prostatic lobes were seen and enlarged. There was a median lobe kind of pointing over a little bit to his right side. Bilateral ureteral orifices were normal. Bladder was normal, but there was a cystic lesion that was anterior, but if you followed it, it actually seemed to attach more laterally on the left prostatic lobe bladder neck area extending into the bladder. Went ahead and did some biopsies of it with just a cold cup and sent it off separately to Pathology and then used the loop to resect the area on the prostate without any difficulty. Ellik was used to remove the chips. Hemostasis was excellent. The chips were sent separately as a specimen too of that prostatic mass area on the left lobe. At the end of the procedure, there were no specimens. The bladder was clear. Went ahead and left some fluid in and removed the cystoscope. A Foley catheter was placed without any difficulty and was put to drainage.