Tanesha Posted Mon 03rd of February, 2020 19:13:22 PM
Agree with 52332-LT, 55899 (prostate biopsy), 52204, bladder biopsy? Excerpt op: It appeared the tumor involved the distal ureter up to the level of the top of the sacroiliac joint. The proximal to the distal ureter was dilated with moderate hydronephrosis. We used the ureteroscope to obtain multiple biopsies using the biopsy forceps. Once this was done, a new 6-French x 26-cm double-J ureteral stent was placed through the cystoscope which was backloaded. Once the stent was in position, we went ahead and placed the resectoscope. His urethra caliber was quite tight proximally. We had to use the 22-French resectoscope. We then used this to obtain samples of the aforementioned irregularities. A small amount of resection was done adjacent to the right ureteral orifice which was left intact. Majority of the resection was done around the left ureteral orifice around the stent where the mucosa was nodular and irregular and some of the bleeding tumor had to be resected from the patient's left prosthetic lobe as this was bleeding. All the chips were collected and fulguration was performed to achieve good hemostasis. A couple of bleeding areas in the posterior bladder were fulgurated as well.
SuperCoder Answered Tue 04th of February, 2020 07:26:55 AM
As per the provided excerpt of the operative note, along with biopsy, tumor resection was also performed at ureteral orifices and at left prostate lobe. It is suggested to add tumor resection codes along with biopsy codes.
Kindly code in the below mentioned manner:
- 52332-59 for cystourethroscopy with ureteral stent placement
- 52204-59 for cystourethroscopy with biopsy
- 52234 for cystourethroscopy with resection of small bladder tumor
- 55899 (Unlisted code) for resection from left lobe of prostate
When submitting an unlisted-procedure code, your documentation should also include an explanatory cover letter. An insurer will decide to pay an unlisted-procedure claim by comparing your procedure description to a similar, listed procedure with an established reimbursement value.