JenLawson
Networker
I am stuck here. The below report is all that the Urology Doctor did during the surgery. He billed a 99253 which I'm sure is incorrect. However, What would the correct code be in this case?
A 76-year-old white male undergoing exploration for sigmoid mass, who was found to have the sigmoid stuck to the left lateral wall and confusion about where the ureter was and I was called in to assist in identification of ureter. When I scrubbed in, an incision was taken, the sigmoid was mobilized, additional retractors were placed to view the retroperitoneum. The psoas muscle was exposed and the mesentery of the sigmoid had been opened. There was a structure with some fat that seemed to be where the ureter should be, but they were uncertain as it did not seem to peristalse when pinched. As such, we dissected a little further into the structures where we seemed to encounter a somewhat slender but structure consistent with a ureter. When pinched gently with the forceps, it seemed to peristalse and had the proper orientation of the ureter, at which point the GI doctor was satisfied and took over the case. Options of cystoscopy, catheterization, and others could be entertained, but the referring surgeon felt sufficiently reassured at this juncture.
Thank you,
Jennifer
A 76-year-old white male undergoing exploration for sigmoid mass, who was found to have the sigmoid stuck to the left lateral wall and confusion about where the ureter was and I was called in to assist in identification of ureter. When I scrubbed in, an incision was taken, the sigmoid was mobilized, additional retractors were placed to view the retroperitoneum. The psoas muscle was exposed and the mesentery of the sigmoid had been opened. There was a structure with some fat that seemed to be where the ureter should be, but they were uncertain as it did not seem to peristalse when pinched. As such, we dissected a little further into the structures where we seemed to encounter a somewhat slender but structure consistent with a ureter. When pinched gently with the forceps, it seemed to peristalse and had the proper orientation of the ureter, at which point the GI doctor was satisfied and took over the case. Options of cystoscopy, catheterization, and others could be entertained, but the referring surgeon felt sufficiently reassured at this juncture.
Thank you,
Jennifer
