Cherie Posted Tue 13th of January, 2015 08:12:53 AM
Hi, I need help with the following notes. Dr. wants to charge a Turp, just want to make sure I'm coding accurately.
"Cystoscope placed, the posterior urethra showed irregularity, but there was oozing from the bladder neck and a significant amount of clots. I removed the cystoscope. I dilated the urethra with Van Buren sounds. I then passed a 28 French Resectoscope sheath w/obturator. I used the Ellik evacuator and removed a significant amount of clots. Once I removed the clots, I then re-evaluated the bladder. Then only mass appeared to be prostatic tissue invading into the bladder. I went ahead and resected the tumor that was into the bladder and bleeding. He had previous radiation therapy and I did not resect into the prostate. I the spent a significant amount of time cauterizing the areas until there was no active bleeding. Cath placed.
SuperCoder Answered Tue 13th of January, 2015 09:21:15 AM
Use code 52601 for the above procedure. Code 52601 represents 'Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)'.