rgeib
Networker
Looking for some advice on the case below as uncertain if coding 52214 and 52001-59 warranted with each code linked to the bleeding bladder neck and blood clots, respectively? Or would just 52214 be justified in this case as 52001 is the column II code. Thanks in advance.
Preoperative diagnosis: refractory gross hematuria
Postoperative diagnosis: same
Procedure findings: The bladder and urethral mucosa was notable for diffuse erythematous changes. consistent with radiation cystitis. Approximately 500cc organized clot evacuated. The bilateral urethral orifices were seen in their expected positions with clear efflux, no evidence of upper tract bleeding. Small bleeding vessels on the bladder neck fulgurated. Cystogram with 250cc with no evidence of vesicoureteral efflux.
Indications for procedure: The patient presents with gross hematuria presumed to be from radiation cystitis. They present today for cystoscopy, fulguration, and clot evacuation.
Description of procedure: The patient was taken to the operating room, placed in supine position on the operating table. The 26-french resectoscope was inserted atraumatically into the bladder. Cystourethroscopy was performed as described in the findings. The bladder and urethral mucosa was notable for diffuse erythematous changes consistent with radiation cystitis. Approximately 500cc organized clot was evacuated through the scope with a Toomey syringe. The bilateral urethral orifices were seen in their expected positions and had clear efflux, no evidence of upper tract bleeding. Small bleeding vessels on the bladder neck were fulgurated with the bipolar loop. At this point, with clot evacuated and the bladder neck fulgurated, we inspected the bladder several times, after filling and emptying the bladder and with irrigation off, and saw no further evidence of active bleeding. There were prominent varices along the trigone but no sites of bleeding. In case they required intravesical treatment for gross hematuria in the future, we performed a cystogram with 250cc and confirmed no vesico ureteral efflux.
We again confirmed that there was good hemostasis and the urethral orifices were far from any areas of fulguration. The bladder was emptied and the resectoscope was removed. A 22-french 3-way catheter was placed without difficulty and the balloon was inflated to 20ml. Continuous bladder irrigation was tye initiated. The patient was the returned to supine position, awakened in the operating room and transported to the recovery room in stable condition.
Preoperative diagnosis: refractory gross hematuria
Postoperative diagnosis: same
Procedure findings: The bladder and urethral mucosa was notable for diffuse erythematous changes. consistent with radiation cystitis. Approximately 500cc organized clot evacuated. The bilateral urethral orifices were seen in their expected positions with clear efflux, no evidence of upper tract bleeding. Small bleeding vessels on the bladder neck fulgurated. Cystogram with 250cc with no evidence of vesicoureteral efflux.
Indications for procedure: The patient presents with gross hematuria presumed to be from radiation cystitis. They present today for cystoscopy, fulguration, and clot evacuation.
Description of procedure: The patient was taken to the operating room, placed in supine position on the operating table. The 26-french resectoscope was inserted atraumatically into the bladder. Cystourethroscopy was performed as described in the findings. The bladder and urethral mucosa was notable for diffuse erythematous changes consistent with radiation cystitis. Approximately 500cc organized clot was evacuated through the scope with a Toomey syringe. The bilateral urethral orifices were seen in their expected positions and had clear efflux, no evidence of upper tract bleeding. Small bleeding vessels on the bladder neck were fulgurated with the bipolar loop. At this point, with clot evacuated and the bladder neck fulgurated, we inspected the bladder several times, after filling and emptying the bladder and with irrigation off, and saw no further evidence of active bleeding. There were prominent varices along the trigone but no sites of bleeding. In case they required intravesical treatment for gross hematuria in the future, we performed a cystogram with 250cc and confirmed no vesico ureteral efflux.
We again confirmed that there was good hemostasis and the urethral orifices were far from any areas of fulguration. The bladder was emptied and the resectoscope was removed. A 22-french 3-way catheter was placed without difficulty and the balloon was inflated to 20ml. Continuous bladder irrigation was tye initiated. The patient was the returned to supine position, awakened in the operating room and transported to the recovery room in stable condition.
