Below is my provider's surgical note. As documented, he performed a robot assisted laparoscopic prostatectomy with bilateral pelvic lymphadenectomy and removal of foreign bodies. Our provider wants to bill CPT 49402 for the removal of the urolift implants but he has T19.1XXA which, according to Codify, is not a covered diagnosis for this procedure. We are comfortable with the CPT code, but we think a Z code would be more appropriate- specifically Z18.10 for Retained Metal Fragments, unspecified.
Can anyone advise what they think?
Procedure:
Robot-assisted laparoscopic radical prostatectomy with bilateral nerve-sparing and bilateral pelvic lymphadenectomy and removal of foreign bodies
The scalpel was used to make an incision to the left of the umbilicus through which the Veress needle was placed. The abdomen was insufflated and a 12 mm port was placed. The scope was then used to guide placement of the remaining three 8mm ports. The robot was docked and the remainder of the procedure was done robotically.
The seminal vesicles and vas were dissected posteriorly in the rectal cul de sac. The bladder was dropped away from the anterior abdominal wall. The pelvic lymphadenectomy was then performed bilaterally removing the lymph nodes between the external iliac vein and obturator nerve from the femoral canal to the bifurcation of the ilia vessels. The endopelvic fascia was incised, and the bladder was then released from the base of the prostate. The posterior plane between the prostate and the rectum was developed bluntly and nerve-sparing was performed bilaterally using Hem-o-lok clip on the pedicles with the release of the neurovascular bundles all the way to the apex.
The patient had a history of Urolift procedure that he had not told s about as the anchors were found protruding from the prostate including two that were into the bladder. These needed to be removed, so three total were dissected out and sent to pathology as gross only specimens. No further metal anchors were left in place that were visible.
The dorsal vein complex and urethra were then divided and the prostate was placed in an EndoCatch bag. The dorsal vein ligating suture was placed and pexed to the anterior pubic symphysis to perform urethral suspension for postoperative support of the urethrovesical anastomosis complex for continence.
The posterior reconstruction was then performed, and then a running vesicourethral anastomosis was performed using double-armed Biosyn suture in watertight fashion such that a J-P drain was not required. The specimens were then extracted through the periumbilical incision. The fascia was closed with Ethibond. All port sites were closed with Biosyn and Dermabond. The procedure was terminated.
Can anyone advise what they think?
Procedure:
Robot-assisted laparoscopic radical prostatectomy with bilateral nerve-sparing and bilateral pelvic lymphadenectomy and removal of foreign bodies
The scalpel was used to make an incision to the left of the umbilicus through which the Veress needle was placed. The abdomen was insufflated and a 12 mm port was placed. The scope was then used to guide placement of the remaining three 8mm ports. The robot was docked and the remainder of the procedure was done robotically.
The seminal vesicles and vas were dissected posteriorly in the rectal cul de sac. The bladder was dropped away from the anterior abdominal wall. The pelvic lymphadenectomy was then performed bilaterally removing the lymph nodes between the external iliac vein and obturator nerve from the femoral canal to the bifurcation of the ilia vessels. The endopelvic fascia was incised, and the bladder was then released from the base of the prostate. The posterior plane between the prostate and the rectum was developed bluntly and nerve-sparing was performed bilaterally using Hem-o-lok clip on the pedicles with the release of the neurovascular bundles all the way to the apex.
The patient had a history of Urolift procedure that he had not told s about as the anchors were found protruding from the prostate including two that were into the bladder. These needed to be removed, so three total were dissected out and sent to pathology as gross only specimens. No further metal anchors were left in place that were visible.
The dorsal vein complex and urethra were then divided and the prostate was placed in an EndoCatch bag. The dorsal vein ligating suture was placed and pexed to the anterior pubic symphysis to perform urethral suspension for postoperative support of the urethrovesical anastomosis complex for continence.
The posterior reconstruction was then performed, and then a running vesicourethral anastomosis was performed using double-armed Biosyn suture in watertight fashion such that a J-P drain was not required. The specimens were then extracted through the periumbilical incision. The fascia was closed with Ethibond. All port sites were closed with Biosyn and Dermabond. The procedure was terminated.