Wiki PLEASE HELP with coding!

cherylbr

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I am new to urology coding. Can I please asked for assistance in billing this op report?



Postoperative Diagnosis: Microhematuria, urinary retention, and benign prostatic hypertrophy.

Procedure Performed: Cystoscopy, bilateral ureteral catheterization, bilateral retrograde pyelogram, cup biopsy of the bladder, fulguration of the prostate, placement of 20-French Foley catheter.

Anesthesia: MAC.

Indications: The patient with persistent urinary retention, prior microhematuria and UTIs.

Findings: Normal penile urethra, 2.5 cm prostate fossa with elevated bladder neck. It is not a tight high bladder neck. There was some anatomic opening. There was minimal lateral lobe tissue. The ureteral orifices had clear efflux bilaterally. There was prompt filling and drainage of collecting system bilaterally with no evidence of mass effect, filling defect, or point of obstruction or J looking. The bladder had grade 3 trabeculations with occasional cellules. There was also catheter reaction and the erythematous red patches throughout, which were irregular. We did a biopsy of this with specimen sent to Pathology. This area was then cauterized for hemostatic purposes and then there was bleeding at the bladder neck in the prostate fossa, which was cauterized as well with Bugbee cauterization. The bladder was filled and emptied and found to be intact. So then it was refilled and a 20-French Foley catheter was placed to gravity drainage. The patient was taken to recovery room awake, alert, and in stable condition. All counts were correct. No complication. No blood transfusion.

I am coming up with 52214 and 52204-59. Doctor states that 74420 was done however, I do not see clear documentation to support this. What are your thoughts on this?

Thanks!
Cheryl B
 
I don't code off the list of procedures performed, I use the description of the operative procedure. My doctors report the description of the procedure separately from the findings. Your report's findings also lists a fulguration of the prostate. I'm not seeing that either.
 
I agree with Wavingwheat - if the process isn't documented within the procedure notes and findings then it didn't happen. Despite fulguration of prostate being listed in procedure performed as well as being noted preop Dx of benign prostatic hypertrophy there is no mention in the procedure notes of the prostate or fulguration. Know I'm late to seeing this but hope our answers gave some guidance.
 
I understand and agree with you as well.
We did mention to the doctor that we did not see this documented within the body of the operative note and he insists it is there. Where can I find documentation to support what you are saying that it must be more clearly documented with the description of the procedure and not just listed as procedure performed?

Thank you!
 
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