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53400 OR 53410?

Viola Posted Mon 12th of July, 2010 13:39:19 PM

Per op note, ok to bill 53410?

The patient was brought into the operating room whereupon general anesthesia was performed. He was elevated in the dorsal lithotomy position. He received antibiotic prophylaxis. There was standard prep and drape over the lower abdomen and genitalia including perineum. Initially routine cystoscopy was carried out. The instrument was guided to the posterior urethra and there did appear to be a narrowing at the very most proximal bulbar urethra and the instrument could not be passed further proximally. It was then removed. A 24-French Foley catheter was then inserted per urethra and advanced down to the most proximal area of the urethra abutting the stricture. Attention was then turned to the perineum. An incision of about 5 cm in length was made in the midline. The incision was deepened with a suction directly to the bulbar urethra to the subcutaneous tissue and then division of the bulbocavernosus musculature. Once again, further access proximally lateral incisions were made more proximally in a lambda type fashion. The bulb of the urethra was completely dissected and dissection continued through the urogenital diaphragm from below. The most proximal extent of the urethra was identified where the catheter could not be move more proximally and at this location, an incision was made ventrally. This immediately identified the scar tissue. This area was carefully dissected and scar tissue at this location was completely excised right down through the membranous urethra. The urethra was divided entirely. At this time, repeat cystoscopy was carried out. This confirmed that the more proximal areas of the urethra were intact including the sphincteric region. Brief inspection within the bladder revealed no particular pathology. At this time, divided urethra was further repaired for a direct anastomosis. Additional scar tissue involved in the bulbar urethra was excised. Thereafter, the repair was carried out with interrupted 3-0 Monocryl suture placed in such a way to reapproximate the segments of the urethra. This was completed over a 20-French Foley catheter, which was passed through the urethra and into the bladder. Afterwards, the catheter was removed and replaced with a soft 18- French coude catheter, which was easily passed into the bladder, again secured. Additional anchoring sutures of 3-0 Vicryl were placed. At this time, closure was carried out.
This involved interrupted 3-0 Vicryl suture to reapproximate the bulbocavernosus musculature as well as soft tissue in the perineum. A running 3-0 Vicryl suture was used to close the wound at the Dartos fascial level, interrupted 4-0 chromic suture was used to close the wound at the skin level. Bacitracin ointment was applied over the wound site followed by fluff dressing and an Athletic supporter. Surgery was completed and there were no apparent complications. The patient was taken down from dorsal lithotomy, awakened from Anesthesia, transferred to his stretcher and then taken to recovery room in satisfactory condition.


SuperCoder Answered Tue 13th of July, 2010 09:32:59 AM

Yes, 53410 is the only code I could come across.

Viola Posted Tue 13th of July, 2010 15:34:15 PM

Alex, my concern is whether the surgery meets the criteria to bill 53410 or if I should stick with 53400?


Viola Posted Mon 26th of July, 2010 06:20:26 AM

Please see above.


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