toria11
Guru
Hi. How would you code this? I always have issues when billing 52214 and 52001 together, so I wasn't sure if maybe I should just bill 52001-22 alone? Thoughts? Thanks!!
Patient was positioned in dorsal lithotomy and all pressure points were padded. Patient was prepped and draped in sterile fashion.
Urethral meatus was dilated to facilitate entry of the resectoscope.
Resectoscope was inserted into the bladder.
The prostate was noted to be extremely friable with multiple areas of bleeding in the prostatic fossa, notably he has a history of radiation for prostate cancer.
Upon entry into the bladder we noted the entire bladder was taking up an extremely large hardened blood clot which must have measured at least 10 cm.
This was painstakingly resected with the resectoscope loop which was very technically challenging given the patient's anatomy and the angle of the cystoscope which was almost vertical.
The vast majority of the clot was able to be extracted however a small amount of the clot in the superior portion of the bladder was unable to be resected due to patient's anatomy.
Apart from this area of the superior bladder, the rest of the bladder was normal with no bladder tumors or bleeding.
The prostate was again surveyed and the areas of bleeding in the prostatic fossa were cauterized with the electrocautery loop. The cystoscope was removed.
At the end of the case there was no bleeding and an 18 French silicone Foley catheter was left.
The patient tolerated the procedure very well and will return to the office in 1 week for Foley catheter removal.
This case was very technically challenging due to the amount of blood clot present and the patient's challenging anatomy. This required extra time to complete this case.
Patient was positioned in dorsal lithotomy and all pressure points were padded. Patient was prepped and draped in sterile fashion.
Urethral meatus was dilated to facilitate entry of the resectoscope.
Resectoscope was inserted into the bladder.
The prostate was noted to be extremely friable with multiple areas of bleeding in the prostatic fossa, notably he has a history of radiation for prostate cancer.
Upon entry into the bladder we noted the entire bladder was taking up an extremely large hardened blood clot which must have measured at least 10 cm.
This was painstakingly resected with the resectoscope loop which was very technically challenging given the patient's anatomy and the angle of the cystoscope which was almost vertical.
The vast majority of the clot was able to be extracted however a small amount of the clot in the superior portion of the bladder was unable to be resected due to patient's anatomy.
Apart from this area of the superior bladder, the rest of the bladder was normal with no bladder tumors or bleeding.
The prostate was again surveyed and the areas of bleeding in the prostatic fossa were cauterized with the electrocautery loop. The cystoscope was removed.
At the end of the case there was no bleeding and an 18 French silicone Foley catheter was left.
The patient tolerated the procedure very well and will return to the office in 1 week for Foley catheter removal.
This case was very technically challenging due to the amount of blood clot present and the patient's challenging anatomy. This required extra time to complete this case.
