quinn1234@tampabay.rr.com
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Hello,
I am new to Urology coding and based on the physicians note, I am concerned there isn't enough information documented to support the codes the physician wants billed. Note reads as follows:
"Informed consent was obtained. Patient was prepped and sterile technique was utilized , 10 cc of 1% lidocaine jelly was placed onto the urethra. A 17 French flexible cystoscope was inserted into the patient's urethra, 250 cc of sterile water was instilled into the bladder for irrigation. There was no meatal stenosis. Th penile and bulbous urethra was without abnormality, the posterior urethra showed bilobar hypertrophy, the bladder was circumferentially examined. There was not masses, the ureteral orifi were orthotopic and effluxing clear urine, there was (moderate/severe) trabeculation of the bladder. There were no diverticula, there was an erythematous lesion suspicious for carcinoma in situ. The mucosa was biopsied using biopsy forceps and the biopsy site was then fulgurated with the Bugbee electrode. The specimen was sent to pathology."
Physician wants to bill for 52224, 52214 and 52204. Based on the above, I do not feel there is enough information to justify the 52224, as he does not give any dimension of the lesion. Again, because of the lack of details, I do not think the 52204 could be captured either. Am I interpreting this correctly? Please help point me in the right direction. Thank you.
I am new to Urology coding and based on the physicians note, I am concerned there isn't enough information documented to support the codes the physician wants billed. Note reads as follows:
"Informed consent was obtained. Patient was prepped and sterile technique was utilized , 10 cc of 1% lidocaine jelly was placed onto the urethra. A 17 French flexible cystoscope was inserted into the patient's urethra, 250 cc of sterile water was instilled into the bladder for irrigation. There was no meatal stenosis. Th penile and bulbous urethra was without abnormality, the posterior urethra showed bilobar hypertrophy, the bladder was circumferentially examined. There was not masses, the ureteral orifi were orthotopic and effluxing clear urine, there was (moderate/severe) trabeculation of the bladder. There were no diverticula, there was an erythematous lesion suspicious for carcinoma in situ. The mucosa was biopsied using biopsy forceps and the biopsy site was then fulgurated with the Bugbee electrode. The specimen was sent to pathology."
Physician wants to bill for 52224, 52214 and 52204. Based on the above, I do not feel there is enough information to justify the 52224, as he does not give any dimension of the lesion. Again, because of the lack of details, I do not think the 52204 could be captured either. Am I interpreting this correctly? Please help point me in the right direction. Thank you.