tnash65
Guest
Hi, I am new to urology and was hoping someone could give me some insight on the following procedure for coding. I am only coming up with 52601 but I feel that may be incorrect. Any recommendations would be greatly appreciated. Thank you!
DRAINS:
A 20-French 2-way Foley catheter to gravity drainage.
SPECIMEN:
Prostatic urethra distally, distal to the verumontanum as a specimen, followed by TUR chips of the bladder neck and prostate.
DISPOSITION:
OR to ASU recovery to home.
DESCRIPTION OF PROCEDURE:
Following induction of anesthesia in supine position, the patient was changed to dorsal lithotomy position and the genital area prepped and draped in the usual sterile fashion.
Following insertion of the resectoscope into the bladder, the bladder was examined. There were no stones, but there was an apparent pretty high bladder neck as well as grade 1 and slightly more advanced trabeculation throughout. The area of interest was located in the posterior right lateral prostatic urethra, just distal to the verumontanum. This was resected with the resectoscope loop in a similar fashion to doing a TURP. This specimen was sent separate. Next, several bites were taken at midline posteriorly at the bladder neck and through the prostate down to the verumontanum itself.
Hopefully, this will help with urination afterward. After cauterizing to ensure hemostasis was completed and collection of all the chips was completed, a catheter was easily advanced into the bladder.
The patient was then allowed to resurface from anesthesia and taken to recovery in stable condition
DRAINS:
A 20-French 2-way Foley catheter to gravity drainage.
SPECIMEN:
Prostatic urethra distally, distal to the verumontanum as a specimen, followed by TUR chips of the bladder neck and prostate.
DISPOSITION:
OR to ASU recovery to home.
DESCRIPTION OF PROCEDURE:
Following induction of anesthesia in supine position, the patient was changed to dorsal lithotomy position and the genital area prepped and draped in the usual sterile fashion.
Following insertion of the resectoscope into the bladder, the bladder was examined. There were no stones, but there was an apparent pretty high bladder neck as well as grade 1 and slightly more advanced trabeculation throughout. The area of interest was located in the posterior right lateral prostatic urethra, just distal to the verumontanum. This was resected with the resectoscope loop in a similar fashion to doing a TURP. This specimen was sent separate. Next, several bites were taken at midline posteriorly at the bladder neck and through the prostate down to the verumontanum itself.
Hopefully, this will help with urination afterward. After cauterizing to ensure hemostasis was completed and collection of all the chips was completed, a catheter was easily advanced into the bladder.
The patient was then allowed to resurface from anesthesia and taken to recovery in stable condition