Wiki 52235 and 52355 - Transurethral resection of bladder tumor, transurethral resection of left distal ureter

JRK

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Hi All! I am looking for some guidance. The physician is showing on the superbill for this surgery 52235 and 52355. I do not believe that 52355 fits this one and that 52235 should cover all of it.

Are there any thoughts on this?



PREOPERATIVE DIAGNOSIS: 2.5 cm papillary bladder tumor, left trigone at the left ureteral orifice.



POSTOPERATIVE DIAGNOSIS: 2.5 cm papillary bladder tumor, left trigone at the left ureteral orifice.


OPERATION: Transurethral resection of bladder tumor, transurethral resection of left distal ureter, mitomycin instillation 40 mg.



ANESTHESIA: GET.



COMPLICATIONS: None.



DESCRIPTION OF PROCEDURE: The patient was prepped and draped in normal sterile fashion. A 26-French resectoscope sheath inserted and pan cystourethroscopy. She had 2.5 cm papillary tumor covering the left trigone, left ureteral orifice. Using a loop electrode, transurethral resection of the bladder tumor and left ureteral orifice down to open normal-appearing left distal ureter was performed into deep muscle. Spot electrocautery was used for hemostasis. An Ellik irrigator used . Reinspection revealed no remaining chips, perforations, or bleeding.



An 18-French Foley catheter was placed. Clear efflux was noted. 40 mg of mitomycin will be placed to dwell for 1 hour in the recovery room and then Foley catheter removed. She will follow up in 2 weeks in the office.
 
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