HI, I was hoping to get some input on this situation where this patient is 74 and has malignant neoplasm of the prostate. Patient has come back in for a Prostate Needle Biopsy and the doctor chose 55700 for code. However the patient has had a prostatectomy previously. The path report says the biopsy was from the prostatic bed. Provider note is as follows:
INDICATIONS FOR PROCEDURE:
Pelvic mass after radical cystectomy
*
DRE: prostate absent; hard mass anterior to rectum on R>L; fixed; mildly tender; approximately 3 cm
*
PROCEDURE AND FINDINGS:
After the patient was positively identified, he was brought to the procedure suite. All questions were answered. Risks were reviewed to include bleeding, infection, sepsis, urinary retention and false negative findings. I confirmed that he had completed his antibiotic (cipro) and Fleets prep. It was confirmed that he has not taken anti-inflammatory medications for at least 1 week. I confirmed that he has no history of anesthetic or bleeding issues. A time out was performed confirming correct patient and procedure.
*
He was placed in the left lateral decubitus position. Transrectal ultrasound probe was inserted and ultrasound was performed.
Subsequently I obtained 3 good biopsy cores from the mass.
*
The probe was removed, and the procedure was terminated.
What are your thoughts? 55700? Unlisted procedure? or something different? Thanks!
Jeff
INDICATIONS FOR PROCEDURE:
Pelvic mass after radical cystectomy
*
DRE: prostate absent; hard mass anterior to rectum on R>L; fixed; mildly tender; approximately 3 cm
*
PROCEDURE AND FINDINGS:
After the patient was positively identified, he was brought to the procedure suite. All questions were answered. Risks were reviewed to include bleeding, infection, sepsis, urinary retention and false negative findings. I confirmed that he had completed his antibiotic (cipro) and Fleets prep. It was confirmed that he has not taken anti-inflammatory medications for at least 1 week. I confirmed that he has no history of anesthetic or bleeding issues. A time out was performed confirming correct patient and procedure.
*
He was placed in the left lateral decubitus position. Transrectal ultrasound probe was inserted and ultrasound was performed.
Subsequently I obtained 3 good biopsy cores from the mass.
*
The probe was removed, and the procedure was terminated.
What are your thoughts? 55700? Unlisted procedure? or something different? Thanks!
Jeff