I'm having an issue finding a cpt code for the removal of the median lobe of the prostate that was protruding into the bladder. Here is the op note:
The patient was prepped and draped in the appropriate fashion. A 22-french cystoscope was inserted through the urethra into the bladder. The bladder was visualized with 30- and 70- degree scopes. Bilateral ureteral orifices were normal. The only abnormality noted was the prostatic median lobe that protruded into the base. The bladder had abnormal mucosa that was worrisome for possible recurrent TCC of the bladder versus inflammation. The resectoscope was placed with a visual obturator. This median lobe of the prostate was resected. There were also some inflammatory polyps that were involving the left prostatic lobe. These were resected and sent with the median lobe currettings. Hemostasis was obtained with electrocautery. The ureters were not damaged......
The only transurethral resection of the prostate I can find is for a TURP 52601 or 52630. I queried the doctor and he said he didn't TURP him. Would 52204 Cystourethroscopy, with biopsy be appropriate since the report stated that currettings were sent to pathology?
Thanks in advance,
J.Fox
The patient was prepped and draped in the appropriate fashion. A 22-french cystoscope was inserted through the urethra into the bladder. The bladder was visualized with 30- and 70- degree scopes. Bilateral ureteral orifices were normal. The only abnormality noted was the prostatic median lobe that protruded into the base. The bladder had abnormal mucosa that was worrisome for possible recurrent TCC of the bladder versus inflammation. The resectoscope was placed with a visual obturator. This median lobe of the prostate was resected. There were also some inflammatory polyps that were involving the left prostatic lobe. These were resected and sent with the median lobe currettings. Hemostasis was obtained with electrocautery. The ureters were not damaged......
The only transurethral resection of the prostate I can find is for a TURP 52601 or 52630. I queried the doctor and he said he didn't TURP him. Would 52204 Cystourethroscopy, with biopsy be appropriate since the report stated that currettings were sent to pathology?
Thanks in advance,
J.Fox