Tammy Posted Wed 01st of March, 2017 10:58:19 AM
A vertical incision was made approximately 1 cm proximal to the urethral meatus at the level of the distal urethra to the bladder neck. The pubocervical fascia was dissected off the vaginal epithelium in a circumferential manner. There was notable chronically infected tissue noted at the midurethra more towards the right and this area was further explored and incised and the urethral diverticular cyst was encountered. There was noted to be chronic infected material and the cyst wall was completely excised. Antibiotic irrigation with Bacitracin was used to irrigate the surgical field. The cyst wall was excised in its entirety. The urethra was reinforced with approximately 4 to 5 sutures of 4-0 PDS in an interrupted fashion.
SPECIMENS REMOVED: Urethral cyst wall. what would the CPT code be? thx.
SuperCoder Answered Thu 02nd of March, 2017 13:05:04 PM
Hi, our expert team is working on your query. We shall revert with the solution soon. Thank you for your patience.
Tammy Posted Thu 02nd of March, 2017 14:33:42 PM
Great . thank you !
Tammy Posted Thu 02nd of March, 2017 14:37:48 PM
I was leaning towards 52305 or 53230
SuperCoder Answered Fri 03rd of March, 2017 01:10:13 AM
Hi, as per documentation, code 53230, Excision of urethral diverticulum (separate procedure); female, should be more approriate for the procedure performed. Also, please check your payer preference before going ahead with the final billing. Thank you.