Sunshine Rose
New
We are new to urology coding. Not sure if we are lacking the right documentation, or if the code for this is just unclear to us.
Does anyone know what CPT codes we would report for this procedure?
Pre Op Dx: Recurrent, refractory chronic prostatitis
Post operative: Same
Procedure: TRUS prostate injection.
Risks and benefits including bleeding, infection, pain/discomfort, need for further procedures, urosepsis, failure to diagnose a clinically significant prostate cancer were discussed. Peri-operative antibiotics were given.
Anesthesia: Local
Pt was brought back to the procedure suite and placed in the right lateral position. A stop and pause identifying the patient, the operative site and surgeon was undertaken. Ultrasound probe was advanced into his rectum. Volumetric survey was undertaken. Volume calculated at 26.41 cc. Lesions: None. Other findings: None
Injection: After local anesthesia was provided 1 g of Rocephin was injected into either lobe of the prostate in 2 needle passes per side. The patient tolerated the procedure well
The probe was withdrawn, procedure was terminated.
Does anyone know what CPT codes we would report for this procedure?
Pre Op Dx: Recurrent, refractory chronic prostatitis
Post operative: Same
Procedure: TRUS prostate injection.
Risks and benefits including bleeding, infection, pain/discomfort, need for further procedures, urosepsis, failure to diagnose a clinically significant prostate cancer were discussed. Peri-operative antibiotics were given.
Anesthesia: Local
Pt was brought back to the procedure suite and placed in the right lateral position. A stop and pause identifying the patient, the operative site and surgeon was undertaken. Ultrasound probe was advanced into his rectum. Volumetric survey was undertaken. Volume calculated at 26.41 cc. Lesions: None. Other findings: None
Injection: After local anesthesia was provided 1 g of Rocephin was injected into either lobe of the prostate in 2 needle passes per side. The patient tolerated the procedure well
The probe was withdrawn, procedure was terminated.