David Posted Tue 04th of August, 2015 16:17:49 PM
I am new to Urology and have a question on how to code the following scenario.
A 75 year old, diagnosed with prostate cancer is in the hospital as an outpatient as he opted to have external beam radiation. Our Urologist is placing the gold fiducial markers.
The transrectal ultrasound probe was then placed. Prostate was visualized with the GE transducer probe. Local was placed in the base of the seminal vesicles 1% lidocaine 5 mL on the left and 5 mL on the right, aspirating before injecting. I then measured the prostate. Images were taken in transverse and sagittal. Prostate volume measured 72 grams, it was 87 in the office for biopsy at that point. The gold fiducial markers were then placed, four of them were placed. One in the mid lateral prostate on both the right and left side. Then one near the base and one near to the apex just to the right of midline. The patient tolerated the procedure well. Transrectal ultrasound probe was removed. There was no bleeding. The patient was cleaned off.
How would this be coded? I see the 55876 and 76872/26. In the past we have coded this as 55876 and 76942/26.
This is being done in the hospital so we do not own the equipment in this case and are only providing the professional component.
Advice please :)
SuperCoder Answered Wed 05th of August, 2015 01:25:40 AM
AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail email@example.com for more information.