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Urology Coding Alert

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Balloon Dilation of Post-Op Bladder Neck Stricture

Published on Sun Jun 10, 2012

Question: How should I report the following procedure for a patient with a bladder neck contracture post-radical retropubic prostatectomy with inability to insert a Foley catheter:Operative Procedure: The patient was placed in the dorsal litho position in the hospital cysto suite. The urethra was anesthetized with Lidocaine jelly. No sedation was given. The 16 French Olympus flexible cystoscope was passed transurethrally down to the bulbous urethra where the external sphincter was seen. Proximal to this, there appeared to be a minimal amount of posterior urethra. There was bladder neck contracture present and the scope would not go into the bladder. With the scope sitting at this level, a 0.038 glide wire was passed through the scope and on into the bladder. This was curled into the bladder. This was left in place and the cystoscope removed. An 8 French balloon dilatation catheter was then passed over the glide wire into [...]
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