Hi, I am hoping that someone can help me with the op note listed below. I coded it one way and the office manager believes that there may be a better way to code this. The patient is a male. Please help.
DX: Neurogenic bladder, chronic urinary retention, and multiple urethral false passages.
Operations: Cystoscopy, replacement of catheter over a wire.
Procedure: After suitable placement the patient on the procedure table, the patient was prepped and draped in the usual sterile fashion. A 2% lidocaine gel was injected per urethra and left for several minutes and then a flexible cystopscope was placed per meatus into the bladder under direct vision. There were multiple false passages present as well as some traumatic changes in the bulbous urethra from previous catheter attempts. Once the bladder was then entered, there was some erythema in the bladder, but no transitional cell changes of concern. A super-stiff Amplatz wire was then placed through the cystoscope into the bladder. The wire was left in place as the cystoscope was removed and then a 22 French 30ml Foley with the tip cut off it and trimmed was placed over the wire and into proper positioning inflated with 80 ml of saline placed to gravity drainage. The catheter was tethered in standard fashion. The patient tolerated the procedure well.
I appreciate any help. Brenda
DX: Neurogenic bladder, chronic urinary retention, and multiple urethral false passages.
Operations: Cystoscopy, replacement of catheter over a wire.
Procedure: After suitable placement the patient on the procedure table, the patient was prepped and draped in the usual sterile fashion. A 2% lidocaine gel was injected per urethra and left for several minutes and then a flexible cystopscope was placed per meatus into the bladder under direct vision. There were multiple false passages present as well as some traumatic changes in the bulbous urethra from previous catheter attempts. Once the bladder was then entered, there was some erythema in the bladder, but no transitional cell changes of concern. A super-stiff Amplatz wire was then placed through the cystoscope into the bladder. The wire was left in place as the cystoscope was removed and then a 22 French 30ml Foley with the tip cut off it and trimmed was placed over the wire and into proper positioning inflated with 80 ml of saline placed to gravity drainage. The catheter was tethered in standard fashion. The patient tolerated the procedure well.
I appreciate any help. Brenda