Hello all,
I am looking for additional opinions on the procedure notes below. I am wanting to charge the 52265 for both of these. I know that in prior years the 52265 was thought only to be billed on a patient with a confirmed IC diagnosis. In my research, I have found that that no longer is the only acceptable use for the cysto hydrodistention, it is also being commonly used for diagnosing as well as the treatment of IC. Would anyone agree to charge the 52005 on this? At best, I am thinking a 52000 if I can't charge a 52265? Thoughts are very much appreciated! p/s lidocaine is noted for both patients under "medication orders tab" for both of the patients, I personally would like to see it noted in the procedure note by the physician- but the order is there, I feel ok charging a 52265.
Procedure note #1:
HISTORY OF PRESENT ILLNESS: The patient presents for cystourethroscopy due to chronic urgency-frequency.
PROCEDURE: The patient was placed in lithotomy position and appropriately prepped and draped. A 0° cystoscope was utilized through a 21 French cystoscope sheath. Transurethral introduction was accomplished without difficulty. Urethroscopy showed no evidence of polyps, diverticula, or other associated pathology. Urethral massage was performed, showing no degrees of sebaceous material. The cystoscope was then withdrawn, and a 70° scope was replaced. Transurethral introduction once again occurred without difficulty, and the cystoscope was fully advanced into the bladder cavity. The bladder was filled to maximum cystometric capacity of 1,000 mL. Thorough inspection identified no evidence of polyps, stones, diverticula, tumor, or trabeculation. The ureteral orifices were seen bilaterally and appeared normal. The trigone of the bladder also was evaluated and appeared normal. The bladder was then drained and reinspected, showing no evidence of focal areas of hemorrhage. Cystoscopic exam was entirely benign. *
IMPRESSION: *
1. Benign cystourethroscopy.
2. Urinary stress incontinence.
PLAN: The patient will now proceed with midurethral sling placement and will be scheduled at her convenience.
Procedure Note #2:
HISTORY OF PRESENT ILLNESS: The patient presents for cystourethroscopy due to chronic urgency-frequency.
PROCEDURE: The patient was placed in lithotomy position and appropriately prepped and draped. A 0° cystoscope was utilized through a 21 French cystoscope sheath. Transurethral introduction was accomplished without difficulty. Urethroscopy showed no evidence of polyps, diverticula, or other associated pathology. Urethral massage was performed, showing no degrees of sebaceous material. The cystoscope was then withdrawn, and a 70° scope was replaced. Transurethral introduction once again occurred without difficulty, and the cystoscope was fully advanced into the bladder cavity. The bladder was filled to maximum cystometric capacity of 550 mL. Thorough inspection identified no evidence of polyps, stones, diverticula, tumor, or trabeculation. The ureteral orifices were seen bilaterally and appeared normal. The trigone of the bladder also was evaluated and appeared normal. The bladder was then drained and reinspected. Cystoscopic exam showed evidence of interstitial cystitis. No additional findings were noted.
IMPRESSION: Interstitial cystitis.
PLAN: The patient will begin bladder instillations. She also will proceed with anterior colporrhaphy and midurethral sling placement.
I am looking for additional opinions on the procedure notes below. I am wanting to charge the 52265 for both of these. I know that in prior years the 52265 was thought only to be billed on a patient with a confirmed IC diagnosis. In my research, I have found that that no longer is the only acceptable use for the cysto hydrodistention, it is also being commonly used for diagnosing as well as the treatment of IC. Would anyone agree to charge the 52005 on this? At best, I am thinking a 52000 if I can't charge a 52265? Thoughts are very much appreciated! p/s lidocaine is noted for both patients under "medication orders tab" for both of the patients, I personally would like to see it noted in the procedure note by the physician- but the order is there, I feel ok charging a 52265.
Procedure note #1:
HISTORY OF PRESENT ILLNESS: The patient presents for cystourethroscopy due to chronic urgency-frequency.
PROCEDURE: The patient was placed in lithotomy position and appropriately prepped and draped. A 0° cystoscope was utilized through a 21 French cystoscope sheath. Transurethral introduction was accomplished without difficulty. Urethroscopy showed no evidence of polyps, diverticula, or other associated pathology. Urethral massage was performed, showing no degrees of sebaceous material. The cystoscope was then withdrawn, and a 70° scope was replaced. Transurethral introduction once again occurred without difficulty, and the cystoscope was fully advanced into the bladder cavity. The bladder was filled to maximum cystometric capacity of 1,000 mL. Thorough inspection identified no evidence of polyps, stones, diverticula, tumor, or trabeculation. The ureteral orifices were seen bilaterally and appeared normal. The trigone of the bladder also was evaluated and appeared normal. The bladder was then drained and reinspected, showing no evidence of focal areas of hemorrhage. Cystoscopic exam was entirely benign. *
IMPRESSION: *
1. Benign cystourethroscopy.
2. Urinary stress incontinence.
PLAN: The patient will now proceed with midurethral sling placement and will be scheduled at her convenience.
Procedure Note #2:
HISTORY OF PRESENT ILLNESS: The patient presents for cystourethroscopy due to chronic urgency-frequency.
PROCEDURE: The patient was placed in lithotomy position and appropriately prepped and draped. A 0° cystoscope was utilized through a 21 French cystoscope sheath. Transurethral introduction was accomplished without difficulty. Urethroscopy showed no evidence of polyps, diverticula, or other associated pathology. Urethral massage was performed, showing no degrees of sebaceous material. The cystoscope was then withdrawn, and a 70° scope was replaced. Transurethral introduction once again occurred without difficulty, and the cystoscope was fully advanced into the bladder cavity. The bladder was filled to maximum cystometric capacity of 550 mL. Thorough inspection identified no evidence of polyps, stones, diverticula, tumor, or trabeculation. The ureteral orifices were seen bilaterally and appeared normal. The trigone of the bladder also was evaluated and appeared normal. The bladder was then drained and reinspected. Cystoscopic exam showed evidence of interstitial cystitis. No additional findings were noted.
IMPRESSION: Interstitial cystitis.
PLAN: The patient will begin bladder instillations. She also will proceed with anterior colporrhaphy and midurethral sling placement.