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Dilation of bladder neck contracure

prideandjy2003

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Is there not a code for cystoscopy with dilation of bladder neck contracture? Everything I see in the CPT book are for urethral strictures?
 

emcee101

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how are the performing the dilation of the BNC? The details of this may be important to finding the correct code.
 

prideandjy2003

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Here's the operative note. Any help would be greatly appreciated!


PREOPERATIVE DIAGNOSES:
1. Known bladder neck contracture after a radical prostatectomy for prostate
cancer.
2. Severe DJD, left hip for left total hip arthroplasty today by Dr. P
OPERATIVE PROCEDURE: Cystoscopy with filiform and follower dilation of a bladder
neck contracture with placement of a 16 French council Foley catheter over a wire.


ASSISTANT: None.

COMPLICATIONS: None.

ANESTHESIA: Anesthetic was general.

Total hip arthroplasty dictated under separate cover by Dr. P

INDICATIONS: Please see my dictated office notes for a detailed discussion of
diagnosis and need for procedure. The pros, cons, risks, benefits, and
alternatives were discussed with the patient. He seemed to understand and wished
to proceed. Consents were signed.

OPERATIVE PROCEDURE: After informed consent and proper identification, the patient
was taken to the operating room. After adequate general anesthetic, he was placed
in the supine position prepped and draped in the usual fashion. We initially tried
a 16 French coude' Foley catheter just to see if we could get lucky, but it just
would not go past the contracture. We then passed a flexible cystoscope. The
pendulous bulbar membranous urethras are normal, but the membranous urethra is
somewhat rigid and open. He does have stress incontinence. He has an open
structured bladder neck. It is rigid and fibrotic, but open. I passed a sensor
guidewire through it and curled it in the bladder. We removed the flexible
cystoscope. We passed multiple flexible Hayman dilator filiform followers up to 20
French. We then passed a 16 French council Foley catheter over the wire and into
the bladder. We secured the Foley with 10 cc in the balloon. The case was turned
over to Dr. P this point. The catheter can be removed at any point
postoperatively when clinically indicated.
 

emcee101

Guru
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The work done here is the same as what would be done for a urethral dilation. The op note does not make it clear where the dilation is. It notes 3 parts of the urethra (pendulous, membranous, bulbar) and says they are normal, and then says the bladder neck is open and structured. I think you are correct to use 52281 for what is documented as being done.
 
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