lcole7465
Expert
The following was coded: 52204, but I don't believe this is correct. The pertinent parts of the op report are below. I'm thinking this should be 52214.
Twenty-two French cystoscope sheath with 30 and subsequently 70 degree lenses was passed into the urinary bladder. Viewing demonstrated normal anterior urethra. Prostate absent. Clear efflux from normally positioned ureteral orifices bilaterally. The bladder was viewed systematically completely. Patient had 1+ trabeculation and radiation changes. No frank bladder cancers were noted. A Zero tip basket was inserted, and a bladder stone which was attached to a metallic clip like structure was extracted with the basket and sent to pathology. Patient had a nodular lesion with normal mucosa about 2 cm in size on the left bladder floor cranial to the left ureteral orifice as well as a discolored yellowish area of mucosa about 0.5 cm in size on the left hemi trigone just caudal to the left ureteral orifice. Both areas were biopsied and treated with the Bugbee electrode generously. This required repeated fulguration, because of radiation cystitis changes. The bladder was drained and scope was withdrawn.
If anyone has any input on this....it would be greatly appreciated.
Twenty-two French cystoscope sheath with 30 and subsequently 70 degree lenses was passed into the urinary bladder. Viewing demonstrated normal anterior urethra. Prostate absent. Clear efflux from normally positioned ureteral orifices bilaterally. The bladder was viewed systematically completely. Patient had 1+ trabeculation and radiation changes. No frank bladder cancers were noted. A Zero tip basket was inserted, and a bladder stone which was attached to a metallic clip like structure was extracted with the basket and sent to pathology. Patient had a nodular lesion with normal mucosa about 2 cm in size on the left bladder floor cranial to the left ureteral orifice as well as a discolored yellowish area of mucosa about 0.5 cm in size on the left hemi trigone just caudal to the left ureteral orifice. Both areas were biopsied and treated with the Bugbee electrode generously. This required repeated fulguration, because of radiation cystitis changes. The bladder was drained and scope was withdrawn.
If anyone has any input on this....it would be greatly appreciated.