Wiki New to Urology Coding

[lcole7465]

I'm new to Urology coding, I've done basic urology coding with anesthesia, but now I'm getting more into the field and need a little assistance.

the provider performed: CO2 Laser Condyloma Ablation penile, Penile Biopsy and Cystoscopy. The op report reads: "Procedure:* Genitalia prepped appears fashion.* Lidocaine jelly placed per urethra.* Inspection of the penis revealed the 2 more prominent condylomatous lesions and then several flat condylomatous lesions about 3 millimeters x 4 millimeters.* Couple other small areas that look like new condylomatous lesions.* I did use dilute ascetic acid.* I did not see any other areas of his acetowhite.* I used local anesthesia to numb up the areas on the penis.*

Then placed flexible cystoscope per urethra bladder. He did have a ring stricture at the bulbar urethra.* Narrowed but just let the cystoscope pass.* Once inside the bladder trabeculations noted.* Circumferential protrusion of the prostate was noted.* No tumors no stones no diverticuli.* Pulling into the prostatic urethra he had reasonably open bladder neck but elements of potential early median lobe as well as lateral lobe hypertrophy noted.* Visual obstruction of bladder neck noted.

Then used the scalpel to remove a condylomatous lesion.* Ventral mid shaft distal.* Sent this for by pathology.* The remaining lesions were treated using CO2 laser ablation 2.5-3 watts.* Lesions treated in their entirety.* Good hemostasis.* At the ventral aspect with a biopsy used silver nitrate stick for hemostasis.* Excellent hemostasis.* Antibiotic ointment applied."


I believe this should be coded: 54057, 11420, 52000.

Any input would be helpful...

Thanks

 

[KCROSS]

Since there are multiple condyloma on the penis, I would use 54065 Destruction of lesion, penis...extensive. It covers any all the methods for treating penile lesions. If you look at the description of 11420, it states, "unless listed elsewhere". 11420-11426 would be used for treating scrotal, inguinal, or perineal lesions--it shouldn't be used for penile lesions because there are specific codes for that location. 52000 is correct. My suggestion is 54065 and 52000. Hope this helps.

 

[lcole7465]

That does help....

Thank you