MelWolfe
New
I am having trouble coding this surgery and I need some help, I have asked a couple coders in my area and they are also unsure of how to handle this scenario also.
Here is the OR report:
Procedure: Cystoscopy, Urethroscopy, Suprapubic catheter removal, failed attempt to put a new suprapubic catheter, Urethral Foley catheter placement.
Details of Procedure:
The patient was brought to the operating room, laid in lithotomy position. His lower abdomen and genitals were prepped and draped in sterile fashion. I started by introducing the rigid cystoscopy though his urethral meatus, which was severely eroded. In his mid penile shaft, there was a very narrow area that I could not pass with cystoscope. Also noted that the patient has diverticulum distal to that narrow area. Using the urethrotome, I did open that the area with cold knife so that I could advance the rigid cystoscope all the way up to his prostatic urethra, which was normal and then to the bladder where both ureteral orifices were normal. I could not identify the suprapubic catheter balloon in the bladder although I could not clearly see the dome of the bladder, but I think the catheter was not reaching the bladder, so it was removed. At this point, a new incision in his suprapubic area was made using a surgical blade after injecting some local anesthetic and a 22-French catheter introducer was pushed through the incision to the pelvis. However, after a few attempts, I could not reach his bladder since it seems that he has a very large fat in his suprapubic area and we could not get the guide to reach his bladder, so I did attempt a put a new suprapubic catheter at this point and since the scope was still in the bladder, I did put a guidewire to the bladder and then a 20 French catheter was applied over the guidewire all the way up to the bladder. The bladder was irrigated and seems functioning at this point. The patient was transferred to recovery room in stable condition.
The code I picked was 51880, but it does not say anywhere that he closed the incision. I asked the surgeon and he said he did not do any suturing at all.
Please help me!!!!!!!!!!
Thank you,
Melinda
Here is the OR report:
Procedure: Cystoscopy, Urethroscopy, Suprapubic catheter removal, failed attempt to put a new suprapubic catheter, Urethral Foley catheter placement.
Details of Procedure:
The patient was brought to the operating room, laid in lithotomy position. His lower abdomen and genitals were prepped and draped in sterile fashion. I started by introducing the rigid cystoscopy though his urethral meatus, which was severely eroded. In his mid penile shaft, there was a very narrow area that I could not pass with cystoscope. Also noted that the patient has diverticulum distal to that narrow area. Using the urethrotome, I did open that the area with cold knife so that I could advance the rigid cystoscope all the way up to his prostatic urethra, which was normal and then to the bladder where both ureteral orifices were normal. I could not identify the suprapubic catheter balloon in the bladder although I could not clearly see the dome of the bladder, but I think the catheter was not reaching the bladder, so it was removed. At this point, a new incision in his suprapubic area was made using a surgical blade after injecting some local anesthetic and a 22-French catheter introducer was pushed through the incision to the pelvis. However, after a few attempts, I could not reach his bladder since it seems that he has a very large fat in his suprapubic area and we could not get the guide to reach his bladder, so I did attempt a put a new suprapubic catheter at this point and since the scope was still in the bladder, I did put a guidewire to the bladder and then a 20 French catheter was applied over the guidewire all the way up to the bladder. The bladder was irrigated and seems functioning at this point. The patient was transferred to recovery room in stable condition.
The code I picked was 51880, but it does not say anywhere that he closed the incision. I asked the surgeon and he said he did not do any suturing at all.
Please help me!!!!!!!!!!
Thank you,
Melinda