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  1. User id : 1825 Posted 2 years ago

    I am looking for a code for the following surgery:

    OPERATIVE PROCEDURE: The patient was taken to the operating room
    after receiving intravenous prophylactic antibiotics. She underwent general
    anesthesia using Allen stirrups. She had sequential compression devices
    functioning bilaterally. The perineum and lower abdomen were prepared and
    draped in the usual sterile fashion. A Foley catheter was placed for bladder
    drainage.

    Examination of the suburethral vaginal epithelium revealed a small area of
    Ethibond suture protruding just medial to the right periurethral sulcus. This
    was grasped with a tonsil clamp and removed with gentle traction. Attention
    was then turned to the large polypoid granulation tissue extruding from the
    left periurethral sulcus. This sinus was irrigated with a large amount of sterile saline. The granulation tissue was removed and the area surrounding the sinus tract was then infiltrated with approximately 10 mL of 1% lidocaine with epinephrine. The sulcus tract was enlarged by making an
    incision in the vaginal epithelium at the inferior aspect of the sinus tract
    being careful to stay away from the urethra and bladder. The epithelial edges
    were then grasped with Adair clamps and the sinus tract probed with tonsil
    clamps. This brought more Ethibond suture down to the opening, and this was
    removed with gentle traction. The remaining sinus tract was probed without
    finding any further foreign material. At this point, a small area of the
    endopelvic fascia overlying the left lateral aspect of the urethra was noted to
    be open. This was oversewn with a figure-of-eight suture of 2-0 Vicryl. The
    vaginal epithelial edges were then trimmed and then reapproximated with 2-0
    Vicryl in a running non locking fashion. Hemostasis was visualized. Iodoform
    gauze was used to pack the sinus tract leaving a small wick at the inferior end
    of the vaginal wound.

    Cystourethroscopy was then performed which showed an area of erythematous
    plaque along the bladder base. Cystoscopic biopsy forceps were then introduced
    to remove 2 small tissue samples from the area. The remaining bladder was
    intact without any further lesions, erosions, lacerations or foreign material.
    There was bilateral ureteral efflux noted from both ureteric orifices
    confirming postprocedural ureteral integrity. The patient tolerated the
    procedure well. All sponge, lap, instrument and needle counts were correct x2
    per the nursing staff at the conclusion of the procedure. The patient was awoken and taken to the recovery room in stable satisfactory condition.

  2. SuperCoder Posted 2 years ago

    52204
    59300-22-51
    Documentation must be submitted with medical records.

  3. User id : 1825 Posted 2 years ago

    Thanks Sanjit but 59300 is related to maternity. The above is not the case. Is there another code I can use?

About this Question

  • Posted by 1825, 2 years ago. There are 3 posts. The latest reply is from 1825.