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apetersen0928

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I am working on coding op reports from the end of sept. I need help coming up with the icd 9 code for incomplete healing status post transurethral resection of bladder tumor. I was thinking V58.49 but wasnt sure if I could just use that code as the only code?
 
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Can you post the op note to look at? or can you give me more details - why are they not healing completely? infection, trauma, bladder puncture?? These options will lead you to a code different ways with different answers. And you definitely have more than one code. I looked at the one you posted; but I don't get a good feel about that one (without more info of course)

If you post the op note I will take a look at it and see what I can find for you.

Good luck girl!!

tori marie :D
 
preop/post op diagnosis: incomplete healing status post transurethral resection of bladder tumor.

procedure preformed: cystoscopy, biopsy of bladder, debridement of necrotic tissue.

details: the patient was given general anesthesia, IV antibiotics were administered, patient was placed in lithotomy position, the perineum prepped and draped sterilely. cystoscopy was undertaken with a 22-French cystoscope. necrotic tissue was debrided with cold cup biopsy forceps and irregular areas were sent for biopsy for pathological diagnosis. there was diffuse bleeding the mucosa cosistent with longstanding inflammation, no evidence of any papillary or sessil elements other than the necrotic firmness, but all tissue that could be debrided with cold cup was done so and the area was fulgurated with electrocautery following the biopsy. the bladder was then left empty and the pt recovered and was sent to recovery room in stable condition.

I hope that helps. the provider doesnt like to add a lot to the reports I have found out and I have only been doing urology coding for 2 weeks now. Thank you for all your help.
 
First - I am so sorry for the delay in getting back with you. I have been ill and just have not been on her :(

I looked and looked though on the DX -- I am *more comfortable* with the following 2 codes:

*998.83 incomplete healing of a surgical wound
*V58.76 Aftercare following surgery on the genitourinary system not elsewhere classified

There is not really codes to specify the type of complication he has provided you. In your statement, it says he does not really like to give a lot of details -- well that has to change now because ICD 10 is just TOO SPECIFIC. If you are not certain or cant delineate what he is DX from the stated DX and the body of the paragraph; you will spend a ton of time chasing him around for clarification. I would ask to speak with him privately about what you will need with the current requirements. But use a lot of care. Maybe ask your admin about the best approach first.

I really hope this helps. Good Luck to you!
 
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