AgnieszkaLakritz
Networker
PREOPERATIVE DIAGNOSIS:
1. Foreign body in bladder
2. Bladder outlet obstruction
POSTOPERATIVE DIAGNOSIS:
Same
PROCEDURE:
1. Cystoscopy and removal of foreign body
2. Transurethral resection of bladder neck
COMPLICATIONS: Small perforation of bladder
FINDINGS:
Digital examination, prostate measured 30 g with slight nodularity on the right side. On cystoscopic examination, the urethra was normal but the bladder outlet was obstructed by high bladder neck which was resected with an open patent channel at the conclusion the procedure. There was a calcified UroLift suture on the right anterior inferior bladder wall that was visualized with the cystoscope. Attempts at removing it with 2 different alligator forceps were unsuccessful 1 of which broke. Therefore the suture had to be resected with the resectoscope and unfortunately small bladder perforation was created by doing so. Therefore catheter was inserted and left in place with 30 cc in the balloon. Hemostasis was noted be good at the conclusion the procedure
DESCRIPTION OF PROCEDURE:
Patient was brought to the operating room after receiving Rocephin 1 g IV. He was placed under monitored anesthesia care and positioned in the dorsolithotomy station. His genitalia were prepped and draped in sterile fashion. 21 French cystoscope was inserted transurethrally and the bladder examined above findings noted. In order to see the suture the 70 degree loop lens was used. Attempts at grabbing suture with 2 different forceps were unsuccessful and 1 of which broke.
Therefore it was decided to resect the bladder neck and use the resectoscope to remove the suture. The large resection loop and cutting current was used to resect the bladder neck in the standard fashion. Hemostasis was then obtained using coagulation current. Once adequate resection had been performed, attention was turned to the UroLift suture.
Using the cutting current the suture was cut releasing the calcified metal component of the suture. This exposed another area of suture which also had a metal component. Given the fear of calcification a deeper resection was performed but an obturator reflex was encountered causing a small perforation of the bladder. Further attempts at removing the suture completely were therefore aborted which seem to retract into the muscle wall. The edges of the area were cauterized with good hemostasis obtained.
I came out with 52315 and 52500. The only issue I have is that both procedures are "separate procedures" . Can they be coded together with XS modifier since I have edit ?
1. Foreign body in bladder
2. Bladder outlet obstruction
POSTOPERATIVE DIAGNOSIS:
Same
PROCEDURE:
1. Cystoscopy and removal of foreign body
2. Transurethral resection of bladder neck
COMPLICATIONS: Small perforation of bladder
FINDINGS:
Digital examination, prostate measured 30 g with slight nodularity on the right side. On cystoscopic examination, the urethra was normal but the bladder outlet was obstructed by high bladder neck which was resected with an open patent channel at the conclusion the procedure. There was a calcified UroLift suture on the right anterior inferior bladder wall that was visualized with the cystoscope. Attempts at removing it with 2 different alligator forceps were unsuccessful 1 of which broke. Therefore the suture had to be resected with the resectoscope and unfortunately small bladder perforation was created by doing so. Therefore catheter was inserted and left in place with 30 cc in the balloon. Hemostasis was noted be good at the conclusion the procedure
DESCRIPTION OF PROCEDURE:
Patient was brought to the operating room after receiving Rocephin 1 g IV. He was placed under monitored anesthesia care and positioned in the dorsolithotomy station. His genitalia were prepped and draped in sterile fashion. 21 French cystoscope was inserted transurethrally and the bladder examined above findings noted. In order to see the suture the 70 degree loop lens was used. Attempts at grabbing suture with 2 different forceps were unsuccessful and 1 of which broke.
Therefore it was decided to resect the bladder neck and use the resectoscope to remove the suture. The large resection loop and cutting current was used to resect the bladder neck in the standard fashion. Hemostasis was then obtained using coagulation current. Once adequate resection had been performed, attention was turned to the UroLift suture.
Using the cutting current the suture was cut releasing the calcified metal component of the suture. This exposed another area of suture which also had a metal component. Given the fear of calcification a deeper resection was performed but an obturator reflex was encountered causing a small perforation of the bladder. Further attempts at removing the suture completely were therefore aborted which seem to retract into the muscle wall. The edges of the area were cauterized with good hemostasis obtained.
I came out with 52315 and 52500. The only issue I have is that both procedures are "separate procedures" . Can they be coded together with XS modifier since I have edit ?