Kim Posted Thu 13th of September, 2012 20:40:02 PM
How would this be coded?
Patient presented with significant irritative symptoms.He had a history of a previous TURP.Cystoscopy showed significant stone burden within teh prostatic urethra, mainly on teh right side with significant regrowth on the right side that is causing obstruction as well as some stones within the bladder as well.
DESCRIPTION OF PROCEDURE:
The patient was prepped and draped in sterile usual fashion. He had some penile abrasions before even starting the case that were evident. We subsequently placed the continuous flow cystoscope sheath with a visual obturator through the urethra and up into the bladder. Once in the bladder, the bladder was carefully and systematically inspected. He had significant trabeculation. He had stones within the bladder as well as stones within the prostatic urethra, mainly on the right. He also had, i could not visualize the right ureteral orifice. The trigone on the right side appeared to be involved with scarring from his previous operation. With this, I stayed well away from this area throughout the entire case except just enough to be able to get rid of the stones that were involving this area. At the end of the case, I still could not see the right ureteral orifice but I believe the area that has the right ureteral orifice was undamaged. With that, vaporization was begun at the 4 and 8 o'clock position again staying well away from the trigone at the 8 o'clock prosition. The majority of the tissue was on the patient's right side. Tissue was vaporized, stone was pushed up into the bladder after the underlying tissue was vaporized. After he had a wide open prostatic urethra, these stones were irrigated out of the bladder. One of these stones was sent off to pathology for analysis. He had the residual regrowth of tissue on the right side that was vaporized completely to the point that he had a wide open prostatic urethra a the end of the case. Meticulous hemostasis was acquired with electrocautery by decompressing the bladder multiple times. The patient tolerated everything well. There were no complications. He was sent to the recovery room in satisfactory condition.
SuperCoder Answered Fri 14th of September, 2012 21:33:04 PM
52630 and 52317/52318 depending upon the size of size or complication(which i dont see in the report)
For resection of residual prostate tissue performed within the postoperative period of a related procedure performed by the same physician, append modifier 78)
Kim Posted Mon 17th of September, 2012 17:58:16 PM
The doc does not mention anywhere that he crushed or fragmented the stones. Would this still be 52317/52318?
SuperCoder Answered Mon 17th of September, 2012 18:16:04 PM
" just enough to be able to get rid of the stones that were involving this area" could qualify for 52317/52318 when the doctor is mentioning in Procedure performed list.