Wiki Bladder Bx, Fulguration, Hydrodistention and Instillation?

[tori.a]

Hi! How would you code the following:

POSTOPERATIVE DIAGNOSIS: Erythema and history of stress incontinence.
PROCEDURE PERFORMED: Cysto, bladder biopsy, fulguration,
hydrodistention, and heparin instillation.
ANESTHESIA: General.
DETAILS OF PROCEDURE: The scope was placed in the bladder without difficulty. The patient had
erythema noted from the right lateral wall to the midline. We did hydrodistention just to see what the
capacity and was 1000 cc. There were some petechiae hemorrhages noted now in this area where the
erythema was. We took a biopsy from the posterior wall and right lateral wall and sent for analysis. We
then fulgurated this area where the biopsy sites were. At this time, no other masses or lesions noted.
Both ureteral orifices were effluxing clear urine. We decided to give the patient heparin instillation with
some Solu-Medrol and Marcaine. A #16 French Foley was placed. The medicine was left in place for an
hour and sent the patient PAR in stable condition. BB 20211221

Thank you!!

 

[liqgold2@aol.com]

I would suggest the following coding for your clinical scenario:
52260 for the bladder distention if the diagnosis is interstial cystitis, if the diagnosis is not interstial cystitis then the dilation would be included in the cystoscopy associated with 52204.
52204-XU for the biopsy with or without the above
51700 is included in 52204 and not separately billable