CPT help for new coder

ggparker14

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Any help is appreciated. Thanks.

operation: cystoscopy, cold knife urethrotomy and TUR of the prostate and bladder neck.

Procedure: The bladder neck was somewhat occluded by recent dilatation and blood clot formation. Using a cold knife urethrotome, the bladder neck was incised and opened to at least a 25-French. The rest of the bladder neck was dilated to 28-French with Van Buren sounds.
A 26-French continous flow resectoscope sheath was placed into the bladder. Transurethral resection of the bladder neck and ther residual prostate was carried out creating a nice opened pear-shaped fossa, preserviang gthe vernumontanum, esternal sphincter and ureteral orifices. All chips were evacuated with the Ellik evacuator and a 22 three-way catheter with a 30 mL balloon was placed.
 

Kelly_Mayumi

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Does the patient have a prior history of prostate surgery? Your note mentioned residual prostate so that makes me ask the question. As far as the urethrotomy, I believe those are included in all the prostate codes in the 52601 section (I don't have my book with me so I cannot check on this for certain).
 
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