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Trans-urethral resection of intra-bladder left ureteral…

Hello everyone! Was hoping someone can guide us in the right direction on this surgery. patient had a nephrectomy done a few days earlier. We are kinda stumped on this one. Thank you in advance :)

Procedure Name: Elective Cystoscopy, Trans-urethral resection of intra-bladder left ureteral inverted stump and fulguration of left ureteral orifice.

History: Intra-bladder inversion of left ureteral stump from prior ureteral avulsion.

Procedure Description: After informed consent was received patient was brought to the operating room and placed in a supine position. Anesthesia was induced. Patient was placed in a dorsal lithotomy position and genitals were prepped and draped in a standard fashion. Appropriate time out was performed. Cystoscopy revealed: Intra-bladder inversion of left ureteral stump from prior ureteral avulsion,
The ureteral stump were resected and the left ureteral orifice was then fulgurated. The ureter was sent to pathology for permanent examination. Hemostasis was achieved. Scope was removed and a Foley catheter was placed and was draining clear urine.

Medical Billing and Coding Forum

Cystoscopy, transurethral resection of bladder tumor/resection of prostatic mass

Please advise if the following procedure should be reported with procedure code 52204 or something else.

Patient was brought to the operating suite, placed in the lithotomy position, prepped and draped in the usual sterile fashion. After adequate general anesthesia was obtained, Ancef was given preoperatively. The cystoscope was inserted per urethra after a time-out was performed. The urethra was normal. Prostatic lobes were seen and enlarged. There was a median lobe kind of pointing over a little bit to his right side. Bilateral ureteral orifices were normal. Bladder was normal, but there was a cystic lesion that was anterior, but if you followed it, it actually seemed to attach more laterally on the left prostatic lobe bladder neck area extending into the bladder. Went ahead and did some biopsies of it with just a cold cup and sent it off separately to Pathology and then used the loop to resect the area on the prostate without any difficulty. Ellik was used to remove the chips. Hemostasis was excellent. The chips were sent separately as a specimen too of that prostatic mass area on the left lobe. At the end of the procedure, there were no specimens. The bladder was clear. Went ahead and left some fluid in and removed the cystoscope. A Foley catheter was placed without any difficulty and was put to drainage.

Medical Billing and Coding Forum