toria11
Guru
Hi! Would you code this as 52500 for bladder neck resection? Help is appreciated!
POSTOPERATIVE DIAGNOSIS:
History of bladder cancer with bladder tumors.
PROCEDURE PERFORMED:
Cystoscopy, transurethral resection of bladder tumors with fulguration.
ANESTHESIA:
General.
INDICATIONS:
Please see the dictated H and P for indications.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room after general anesthesia was instituted by the anesthesiologist. The patient was put in dorsal lithotomy position and prepped and draped in usual sterile fashion. Using a 21-French cystoscope sheath, the bladder was entered via the urethra. Bladder was examined with 30- and 70-degree lenses. Patient with papillary tumor at the bladder neck and around the right ureteral orifice and almost completely in different spots around the bladder neck. The cystoscope sheath was removed. A 25-French resectoscope with an obturator was entered in the bladder via the urethra using standard electrode loop. We resected the right bladder neck superficial and deep, floor superficial and deep, the right ureteral orifice, left bladder neck and then cauterized any small tumors and mucosal abnormalities around the bladder neck. After this was completed and all tumors had been Elliked out and we had good hemostasis, resectoscope was removed and a 22-French 3-way Foley catheter was inserted in the bladder via the urethra. The balloon was inflated with 15 mL of sterile water. The patient was taken down out of dorsal lithotomy position, extubated, and taken to the recovery room in stable condition. 20211122 CM
POSTOPERATIVE DIAGNOSIS:
History of bladder cancer with bladder tumors.
PROCEDURE PERFORMED:
Cystoscopy, transurethral resection of bladder tumors with fulguration.
ANESTHESIA:
General.
INDICATIONS:
Please see the dictated H and P for indications.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room after general anesthesia was instituted by the anesthesiologist. The patient was put in dorsal lithotomy position and prepped and draped in usual sterile fashion. Using a 21-French cystoscope sheath, the bladder was entered via the urethra. Bladder was examined with 30- and 70-degree lenses. Patient with papillary tumor at the bladder neck and around the right ureteral orifice and almost completely in different spots around the bladder neck. The cystoscope sheath was removed. A 25-French resectoscope with an obturator was entered in the bladder via the urethra using standard electrode loop. We resected the right bladder neck superficial and deep, floor superficial and deep, the right ureteral orifice, left bladder neck and then cauterized any small tumors and mucosal abnormalities around the bladder neck. After this was completed and all tumors had been Elliked out and we had good hemostasis, resectoscope was removed and a 22-French 3-way Foley catheter was inserted in the bladder via the urethra. The balloon was inflated with 15 mL of sterile water. The patient was taken down out of dorsal lithotomy position, extubated, and taken to the recovery room in stable condition. 20211122 CM