valerieeanderson
Networker
I have this documentation, the provider is saying it should be 51040 but coder is stating it should be 51102. I don't see that urine was aspirated so I'm thinking 51040 but could use your guys perspective. TIA!
Description of Operative Technique
Bilateral SCDs and IV antibiotic were administered in pre-op holding area. Patient was wheeled back to OR and transferred to OR table. Patient was placed on supine position. General anesthesia was induced in a smooth fashion. Patient was placed on dorsal lithotomy position with all pressure points padded. A surgical time out was performed to identify correct patient, procedure and site. The genitalia and lower abdomen was prepped and draped in a standard fashion.
We began the case by inserting a 22Fr rigid cystoscope into the bladder, and the urethra was noted to be normal. We systematically surveyed the bladder mucosa and the findings were noted as above.
We turned our attention to the dome of the bladder. A site of puncture was confirmed by direct vision, roughly about 2 finger breath above the pubic symphysis.
We then introduced needle perpendicular to the skin and advanced it toward the bladder under direct vision. After we removed the stylet, urine returned immediately. Wire was passed into the bladder and the needle was removed. A 1 cm incision was made around the wire. Next, Amplatz dilator was used to serially dilated the tract to 24 Fr, allowing the introduction of the trocar to the bladder. The 18 fr silicone catheter was introduced into the bladder. 10 cc sterile water was used to inflate the balloon. The trocar was removed. The catheter was connected to gravity drainage.
Patient tolerated the procedure well. There was no immediate complications. Patient was awoken and extubated without difficulty. Patient was transferred to PACU in stable condition. The attending physician, Dr. Funk, was present and scrubbed in for the entirety of the procedure.
Description of Operative Technique
Bilateral SCDs and IV antibiotic were administered in pre-op holding area. Patient was wheeled back to OR and transferred to OR table. Patient was placed on supine position. General anesthesia was induced in a smooth fashion. Patient was placed on dorsal lithotomy position with all pressure points padded. A surgical time out was performed to identify correct patient, procedure and site. The genitalia and lower abdomen was prepped and draped in a standard fashion.
We began the case by inserting a 22Fr rigid cystoscope into the bladder, and the urethra was noted to be normal. We systematically surveyed the bladder mucosa and the findings were noted as above.
We turned our attention to the dome of the bladder. A site of puncture was confirmed by direct vision, roughly about 2 finger breath above the pubic symphysis.
We then introduced needle perpendicular to the skin and advanced it toward the bladder under direct vision. After we removed the stylet, urine returned immediately. Wire was passed into the bladder and the needle was removed. A 1 cm incision was made around the wire. Next, Amplatz dilator was used to serially dilated the tract to 24 Fr, allowing the introduction of the trocar to the bladder. The 18 fr silicone catheter was introduced into the bladder. 10 cc sterile water was used to inflate the balloon. The trocar was removed. The catheter was connected to gravity drainage.
Patient tolerated the procedure well. There was no immediate complications. Patient was awoken and extubated without difficulty. Patient was transferred to PACU in stable condition. The attending physician, Dr. Funk, was present and scrubbed in for the entirety of the procedure.