toria11
Guru
Could someone please help me determine if this should be billed with 55821 or 55831? The note says the incision was extraperitoneal and it seems the bladder was opened which would point me to 55821, but the doctor selected to bill 55831 and the prostatic capsule was incised directly so I'm just going back and forth. Please let me know what code you would choose and why. Thank you!!
Indications: 86 y.o. male who is having a procedure for Benign prostatic hyperplasia with lower urinary tract symptoms [N40.1]
Procedure Details: Patient was properly identified and brought back to the operating room where he was placed supine on the operating table. A proper time-out was performed. Under direction Anesthesiology, patient is intubated use under general anesthetic. Ancef 2 g IV were given. Patient was prepped and draped in normal sterile surgical fashion including his indwelling suprapubic catheter. A low midline incision was made from his pubic symphysis to his umbilicus. This included the SP tube site. We were able to stay extraperitoneal and locate the prostate. The periprostatic fat was dissected off the prostate to expose the capsule. 0 Vicryl suture interrupted sutures were placed horizontally along the prostatic capsule to help with control capsular bleeding. The prostatic capsule was entered with a 15 blade scalpel by making a transverse incision across the prostatic capsule. The the adenoma was removed by blunt dissection. Once the adenoma was removed meticulous hemostasis was achieved with pinpoint electrocautery initially. The inside the bladder was easily visible with the SP tube in place. Using Metzenbaum scissors I divided the bladder neck at the 6 o'clock position this was then anchored down to the floors of the prostatic capsule at the 1:00 p.m. and 11:00 a.m. positions using 2-0 Vicryl suture. A 22 French 3 way Foley catheter was placed in his penis down his return into the bladder this was done under direct visualization. 10 ml of sterile water placed in the balloon to secure the catheter in place. The capsule of the prostate was reapproximated with a running 0 Vicryl suture. Once the capsule was closed hemostasis appeared to be excellent. The SP tube was removed from the bladder and the bladder cystotomy was closed with the interrupted 2-0 Vicryl. A 15 French JP drain was placed through the left lower quadrant and secured with a 3-0 nylon. The fascia was closed with a looped PDS. Skin was closed with 3-0 Vicryl and 4-0 Monocryl. The catheter irrigated light pink at the end the case without evidence of any clots. This concluded the procedure. Sponge, instrument, and needle counts were correct at the end the case. Estimated blood loss 400 ml. Patient was extubated and sent to recovery in stable condition without immediate complications. RE 20220428
Indications: 86 y.o. male who is having a procedure for Benign prostatic hyperplasia with lower urinary tract symptoms [N40.1]
Procedure Details: Patient was properly identified and brought back to the operating room where he was placed supine on the operating table. A proper time-out was performed. Under direction Anesthesiology, patient is intubated use under general anesthetic. Ancef 2 g IV were given. Patient was prepped and draped in normal sterile surgical fashion including his indwelling suprapubic catheter. A low midline incision was made from his pubic symphysis to his umbilicus. This included the SP tube site. We were able to stay extraperitoneal and locate the prostate. The periprostatic fat was dissected off the prostate to expose the capsule. 0 Vicryl suture interrupted sutures were placed horizontally along the prostatic capsule to help with control capsular bleeding. The prostatic capsule was entered with a 15 blade scalpel by making a transverse incision across the prostatic capsule. The the adenoma was removed by blunt dissection. Once the adenoma was removed meticulous hemostasis was achieved with pinpoint electrocautery initially. The inside the bladder was easily visible with the SP tube in place. Using Metzenbaum scissors I divided the bladder neck at the 6 o'clock position this was then anchored down to the floors of the prostatic capsule at the 1:00 p.m. and 11:00 a.m. positions using 2-0 Vicryl suture. A 22 French 3 way Foley catheter was placed in his penis down his return into the bladder this was done under direct visualization. 10 ml of sterile water placed in the balloon to secure the catheter in place. The capsule of the prostate was reapproximated with a running 0 Vicryl suture. Once the capsule was closed hemostasis appeared to be excellent. The SP tube was removed from the bladder and the bladder cystotomy was closed with the interrupted 2-0 Vicryl. A 15 French JP drain was placed through the left lower quadrant and secured with a 3-0 nylon. The fascia was closed with a looped PDS. Skin was closed with 3-0 Vicryl and 4-0 Monocryl. The catheter irrigated light pink at the end the case without evidence of any clots. This concluded the procedure. Sponge, instrument, and needle counts were correct at the end the case. Estimated blood loss 400 ml. Patient was extubated and sent to recovery in stable condition without immediate complications. RE 20220428