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please advise on coding

louise Posted Thu 02nd of May, 2019 11:59:41 AM
52234 52234 52341 52232 The bladder was inspected in its entirety and there were 2 lesions, one on the left posterior wall and one on the right lateral wall. There were less than 1 cm in size, adherent to the wall and seemed consistent with small hemangiomas. These lesions were biopsied with the cold cup forceps and then fulgurated. A double floppy wire was placed in the left ureteral orifice and advanced to the level of the kidney. The distal intramural ureter was very tight and would barely accept an 8/10 dilator, but an attempt was made at passing a Flex-X ureteroscope up into the ureter and the ureter was too tight. At this point, it was decided to dilate the intramural ureter with a 15-French 4 cm UroMax balloon. This was done with the balloon and the distal intramural ureter was dilated to 15-French without difficulty. The 8/10 was then replaced, and a second double floppy wire was advanced to the level of the kidney. The flexible ureteroscope was advanced, and the kidney was inspected in its entirety. The upper pole and lower pole were noted to have some prominent papillae. There was a small area of erythema in the upper pole likely consistent with some irritation from the wire placement, but this area was brush biopsied and sent for cytology. The ureter was inspected in its entirety on the way out, and access sheath was remove. double-J ureteral stent was placed over the wire under fluoroscopic guidance with good coil in the kidney and the bladder.  
SuperCoder Answered Fri 03rd of May, 2019 07:33:16 AM

Hi Louise,

 

Thanks for your question.

 

Codes assigned by you are absolutely correct. The only thing to note is that, code 52332 has CCI edit with code 52234. So, you should not report code 52332 with 52234.

 

Please feel free to write if you have any question.

 

Thanks

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