Nicole Posted Sat 30th of December, 2017 20:33:28 PM
Diagnosis: meatal irregular -appearing lesions involving the edge meatus at the junction with the urethra more prominent on right side that involved two-thirds from dorsal to ventral. Left side small ventral meatal extending 3-4mm.
Flexible cystourethroscopy was done. The right edge of the meatus and into the urethra was excised for a total length approximately of 8mm. The sliver of skin was excised and a meatoplasty was done by approximating the glanular to the urethral edges with running 5-0 chromic. On the left side a smaller lesion was seen ventrally near the junction of the urethral epithelium and the glans. This was fulgurated with a Bugbee electrode.
Would this be CPT 53460?
SuperCoder Answered Tue 02nd of January, 2018 07:12:59 AM
In the CPT code 53460, the provider enlarges the meatal opening by making an incision in it to treat meatal stenosis, or narrowing, and reconstructs any part of urethra near the meatus. With this you have performed lesion fulguration too, this is an access to the procedure 53460, so add modifier 22 (Increased procedural services) with the procedure, also attached the op-report to support modifier 22.
If the procedure only performed for the fulguration of lesions, then used CPT code 52214. In the CPT 52214, cystourethroscopy is the inspection of the interior of the bladder, the urethra, prostatic urethra, and ureteric openings by a cystoscope that is passed through the urethra and into the bladder. It is a common diagnostic procedure for conditions ranging from urinary tract infections and stress incontinence, to the follow up of bladder cancer treatment. This specific procedure includes fulguration, which is the introduction of an electric current to eradicate tissue that is diseased.
Crosscheck the reason for surgery and select the appropriate code.