OPERATION: Cystoscopy, transurethral resection of bladder tumor,
right diagnostic ureteroscopy with biopsies of right distal ureter,
right retrograde pyelogram, and right ureteral stent change.

DESCRIPTION OF OPERATION:
The patient was identified in the waiting area and brought into the
room. Preoperative antibiotics consisting of Levaquin and
gentamicin were provided, and general anesthesia administered. The
patient was placed in lithotomy position, then prepped and draped in
a standard sterile surgical fashion. Time-out was performed.
Consent and laterality were verified. Cystoscopy was performed
using a 30-degree scope. No strictures in the anterior urethra.
Open prostatic fossa consistent with prior BPH surgery. The bladder
was entered. The patient had extensive grade 3 or 4 trabeculation
throughout the bladder along with diverticula in the posterior
aspect of the bladder. The stent was noted emanating from the right
ureteral orifice. Just above and lateral to the right ureteral
orifice, the patient had extensive inflammation with the medial part
of that inflammation suspicious for bladder cancer. This appears to
be the site of prior TURBT. At this point, I inserted a 26-French
resectoscope, and using sterile water with continuous irrigation, I
went ahead and resected the mass, which was extending close to the
right ureteral orifice along with the inflammation lateral to it.
This measured approximately 2.5 cm in total. The resection base was
cauterized. Next, the patient also was noted to have inflammation
extending more laterally. I did take a quick resection of that and
sent it for specimen to confirm this is not tumor. After confirming
there was no bleeding from the resection site and all the mass
fragments were evacuated using the Ellik evacuator, I reinserted the
22-French cystoscope and pulled the stent out of the urethral
meatus. A Sensor wire was then passed through the stent into the
right kidney. I then assembled a short rigid ureteroscope and
advanced it through the right ureteral orifice. I then performed a
retrograde study through the scope revealing a filling defect at the
area of the UVJ and concentric filling defects approximately 3 cm
proximal to the UVJ. I then inserted the ureteroscope through the
right ureteral orifice and inspected the ureter carefully. The
patient had inflammation at the area of the UVJ proximal to it and
some inflammatory protrusions about an inch from the UVJ. Proximal
to that, I inserted the scope and the mucosa appeared smooth without
any defect. I was able to pass the ureteroscope easily to the mid
ureter above the pelvic inlet. Retrograde revealed some
hydronephrosis without filling defect in the mid and proximal
ureter, and no obvious filling defects in the collecting system.
Next, a flexible biopsy cup was introduced through the ureteroscope
and 4 separate biopsies were performed from the UVJ inflammation
area as well as the concentric inflammation proximal to it. The
specimens were small and were handed to pathology for quick
processing. Reinspection revealed no active bleeding. I removed
the ureteroscope and using fluoroscopic guidance and cystoscopy,
placed a 6 x 26 stent over the wire. The stent was noted to coil
nicely in the kidney and in the bladder. Again inspection of the
bladder revealed no bleeding. A 20-French Foley catheter was
inserted and balloon inflated with 10 mL of sterile water. The
patient tolerated the procedure well.

I’ve come up with 52235 for the TURBT, 52354 for the ureteral biopsy, 52332 for stent change, and 74420-26 for the pyelogram. However, my encoder indicates that 52332 bundles into 52235 and 52235 itself bundles into 52354 (but 52332 does NOT bundle into 52354). Are any modifiers warranted here or should I just be billing 52354 & 74420-26? Any help would be appreciated. Thanks.