toria11
Guru
Hi! Would you code this with 52214? Thanks for your help!
Postoperative Diagnosis: Urinary retention
Procedure: Cystoscopy and plasma button vaporization of bladder neck
Indications: patient went into urinary retention. On local cysto was found to have an enlarged bladder neck. Presents this time for vaporization
Findings: Urethra was tight meatus. Bladder neck was elevated and obstructed. Bladder had 2+ trabeculations without any stones or tumors.
Procedure: Patient brought to cystoscopy suite and after proper time-out was performed patient was administered general anesthesia was placed in the dorsal lithotomy position and prepped and draped in usual sterile fashion. Attempts at passing a 26 French visual operatir unsuccessful. The urethral meatus was then dilated with sequential dilatoes from 18 French to 30 French. Then the 26 French visual operator was passed per urethra into the bladder neck. The operator was removed and the plasma button was placed in the sheath. The tissue was then vaporized to open up the bladder neck and urethral channel. Hemostasis achieved wit the plasma button. Scope was removed. Twenty-two French 3 way Foley catheter was placed in the bladder to continuous bladder irrigation. Efflux was clear. Patient sent to recovery in stable condition.
Postoperative Diagnosis: Urinary retention
Procedure: Cystoscopy and plasma button vaporization of bladder neck
Indications: patient went into urinary retention. On local cysto was found to have an enlarged bladder neck. Presents this time for vaporization
Findings: Urethra was tight meatus. Bladder neck was elevated and obstructed. Bladder had 2+ trabeculations without any stones or tumors.
Procedure: Patient brought to cystoscopy suite and after proper time-out was performed patient was administered general anesthesia was placed in the dorsal lithotomy position and prepped and draped in usual sterile fashion. Attempts at passing a 26 French visual operatir unsuccessful. The urethral meatus was then dilated with sequential dilatoes from 18 French to 30 French. Then the 26 French visual operator was passed per urethra into the bladder neck. The operator was removed and the plasma button was placed in the sheath. The tissue was then vaporized to open up the bladder neck and urethral channel. Hemostasis achieved wit the plasma button. Scope was removed. Twenty-two French 3 way Foley catheter was placed in the bladder to continuous bladder irrigation. Efflux was clear. Patient sent to recovery in stable condition.