Wiki Please help code this surgery

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jbolden

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A 21 French rigid cystoscope sheath was passed through the urethra and into the bladder. All aspects of bladder mucosa was visualized. Patient had a substantial amount of increased vascularity around the trigone and the prostate urethra. There was no raised lesions of the bladder. There was some irregularity of the right lateral lobe of the prostate.

Bilateral retrograde ureterogram's are carried out with 5 French ureteral catheters and there was no evidence of any hydronephrosis or any ureteral filling defects.

Biopsy forceps was used to biopsy an area of irregularity of the prostate urethra and then another area of the trigone and posterior bladder wall. These were passed off the table.

These areas were cauterized as well as multiple areas cauterized where there look to have been some potential bleeding from increased vascularity from his radiation cystitis.

*I am not sure if "Cauterized" can be billed as "Fulguration" and no size is mentioned to bill within cpt codes 52234-52240. IF the note is amended to include size could one of these codes be billed?
 
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Fulguration: A procedure that uses heat from an electric current to destroy abnormal tissue, such as a tumor or other lesion. It may also be used to control bleeding during surgery or after an injury.

Kinda sounds the same to me.
 
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Have you looked at 52004?

This is from Select Coder:

52204 - Cystourethroscopy with biopsy(s)

Description of Procedure
Cystourethroscopy is performed to visualize the inside of the bladder and urethra and tissue samples are obtained. The urethra is cleansed with antiseptic solution. A rigid or flexible cystoscope is introduced through the urethra into the bladder. The bladder may be filled with sterile saline to allow better visualization of the bladder wall. The bladder is inspected and the ureteral orifices are identified and examined. Biopsy forceps are introduced through the cystoscope and tissue samples are obtained. The bladder and urethra are re-inspected following biopsy and any bleeding is controlled. The cystoscope is removed.

 
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EMetiva said:
Have you looked at 52004?

This is from Select Coder:

52204 - Cystourethroscopy with biopsy(s)

Description of Procedure
Cystourethroscopy is performed to visualize the inside of the bladder and urethra and tissue samples are obtained. The urethra is cleansed with antiseptic solution. A rigid or flexible cystoscope is introduced through the urethra into the bladder. The bladder may be filled with sterile saline to allow better visualization of the bladder wall. The bladder is inspected and the ureteral orifices are identified and examined. Biopsy forceps are introduced through the cystoscope and tissue samples are obtained. The bladder and urethra are re-inspected following biopsy and any bleeding is controlled. The cystoscope is removed.

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A 21 French rigid cystoscope 52000 sheath was passed through the urethra and into the bladder. All aspects of bladder mucosa was visualized. Patient had a substantial amount of increased vascularity around the trigone and the prostate urethra. There was no raised lesions of the bladder. There was some irregularity of the right lateral lobe of the prostate.

Bilateral retrograde ureterogram's 52005.59-74420 are carried out with 5 French ureteral catheters and there was no evidence of any hydronephrosis or any ureteral filling defects.

Biopsy forceps was used to biopsy an area of irregularity of the prostate urethra 52204 and then another area of the trigone and posterior bladder wall. These were passed off the table.

These areas were cauterized as well as multiple areas cauterized 52204 (continued) where there look to have been some potential bleeding from increased vascularity from his radiation cystitis.

This would be my code set for this.

52204 - look at the cauterizing as cleaning up his work from the biopsy.

52005.59

74420.26
 
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