the provider performed: CO2 Laser Condyloma Ablation penile, Penile Biopsy and Cystoscopy. The op report reads: "Procedure:* Genitalia prepped appears fashion.* Lidocaine jelly placed per urethra.* Inspection of the penis revealed the 2 more prominent condylomatous lesions and then several flat condylomatous lesions about 3 millimeters x 4 millimeters.* Couple other small areas that look like new condylomatous lesions.* I did use dilute ascetic acid.* I did not see any other areas of his acetowhite.* I used local anesthesia to numb up the areas on the penis.*
Then placed flexible cystoscope per urethra bladder. He did have a ring stricture at the bulbar urethra.* Narrowed but just let the cystoscope pass.* Once inside the bladder trabeculations noted.* Circumferential protrusion of the prostate was noted.* No tumors no stones no diverticuli.* Pulling into the prostatic urethra he had reasonably open bladder neck but elements of potential early median lobe as well as lateral lobe hypertrophy noted.* Visual obstruction of bladder neck noted.
Then used the scalpel to remove a condylomatous lesion.* Ventral mid shaft distal.* Sent this for by pathology.* The remaining lesions were treated using CO2 laser ablation 2.5-3 watts.* Lesions treated in their entirety.* Good hemostasis.* At the ventral aspect with a biopsy used silver nitrate stick for hemostasis.* Excellent hemostasis.* Antibiotic ointment applied."
I believe this should be coded: 54057, 11420, 52000.
Any input would be helpful…
Thanks