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cysto w/ attempted stent and fluff removal

Tanesha Posted Tue 11th of June, 2019 00:44:14 AM
Came up with 52005 initially, but not sure about the "fluff." Evidence of prior bladder resection, healing. Some unresected anterior dome bladder wall tumor papillary cannot be completely resected. Unable to find the right UO to place stent for the right hydroureteronephrosis. Indigo carmine was given and noted coming from left collecting system. The area of the right UO was seen stained with blue but no dye was coming out. The area was already thin from the prior TURBT so no further resection was done to avoid bladder perforation. The tissue medial to this area was resected minimally to be able to remove the "fluff" burnt tissue from the prior resection
SuperCoder Answered Tue 11th of June, 2019 08:49:42 AM

Hello Tanesha,

Thank you for your question.

 

As per the above provided documentation, we could determine that the provider has performed cystourethroscopy and inspected the bladder. The resection part at the bottom of the documentation is still unclear.

 

Please provide us with more information of the procedure performed along with the diagnosis. The provided information will help us determining the appropriate code(s).

 

Thanks

Tanesha Posted Tue 11th of June, 2019 13:42:21 PM
Cystoscopy was performed and the diagnosis is Bladder Cancer and Rt. Hydronephrosis - OP note - The cystoscope was placed and the bladder inspected. The findings as noted above was seen. Evidence of prior bladder resection, healing. Some unresected anterior dome bladder wall tumor papillary cannot be completely resected. Unable to find the right UO to place stent for the right hydroureteronephrosis. Indigo carmine was given and noted coming from left collecting system. The area of the right UO was seen stained with blue but no dye was coming out. The area was already thin from the prior TURBT so no further resection was done to avoid bladder perforation. The tissue medial to this area was resected minimally to be able to remove the "fluff" burnt tissue from the prior resection. At this point I stopped the procedure. Will plan to place right perc nephrostomy tube.
SuperCoder Answered Wed 12th of June, 2019 08:53:06 AM

Hello Tanesha,

Thank you for the additional information.

 

If the medial tissue that was resected is a tumor, then report the procedure basis the size of the tumor resection from the below suggested codes.

52234- Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm).

52235- Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm).

52240- Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s).

 

Also, if the resected tissue is not a tumor, then report the procedure with CPT® code 53899- Unlisted procedure, urinary system, as there is no specific code defining the procedure performed in the above documentation.

 

Hope that helps!

Thanks

Tanesha Posted Wed 12th of June, 2019 16:57:20 PM
Ok thank you. I was thinking about the unlisted code for this. I didn't think the medial tissue was the tumor and no path was taken.
SuperCoder Answered Thu 13th of June, 2019 03:20:41 AM

Hello Tanesha,

 

If the resected medial tissue wasn’t a tumor, then you may use the unlisted code 53899- Unlisted procedure, urinary system; for the above scenario.

Note: When reporting a procedure with an unlisted code, submit a cover letter explaining the reason for choosing the unlisted code instead of a defined, active code. Include one or more similar codes and compare your service to those codes to justify the claim amount you are billing. Also include the operative notes or other relevant documentation to strengthen the claim and to avoid a possible denial.

 

Thanks!

Tanesha Posted Wed 26th of June, 2019 08:15:15 AM
The fluff came back as not a tumor so 53899 applies. Considering the whole op note and the attempted stent, only 53899, correct? The stent was never inserted because the Ureteral orifice situation.
SuperCoder Answered Thu 27th of June, 2019 07:23:07 AM

Yes, you are right, the only option to report the performed procedure is by CPT® code 53899- Unlisted procedure, urinary system.

 

Thanks

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