How would you bill the following prostate biopsy?:
Procedure Name
TRANSPERINEAL ULTRASOUND-GUIDED PROSTATE BIOPSY - TARGETED (LEFT PERIPHERAL LEAD LESION + MULTIPLE OTHERS THROUGHOUT THE PROSTATE)
Consent
YES
Indication
ELEVATED PSA
Location
OUTPATIENT SURGERY CENTER
Description
With the patient in the lithotomy position the perineal skin was injected with local anesthetic. Under the guidance of a transrectal ultrasound probe, a spinal needle was used to infiltrate the prostatic capsule. At this point a using a special trocar needle, 21 core biopsies were carried out of the prostate at the base, apex and mid portion of both Right and Left lobes.
The patient tolerated well the procedure. Mild urethral bleeding was observed. The patient was told to drink plenty of water for few hrs.
The biopsies were sent to pathology.
Thanks for any help you may be able to give. Still getting used to the new codes.
Procedure Name
TRANSPERINEAL ULTRASOUND-GUIDED PROSTATE BIOPSY - TARGETED (LEFT PERIPHERAL LEAD LESION + MULTIPLE OTHERS THROUGHOUT THE PROSTATE)
Consent
YES
Indication
ELEVATED PSA
Location
OUTPATIENT SURGERY CENTER
Description
With the patient in the lithotomy position the perineal skin was injected with local anesthetic. Under the guidance of a transrectal ultrasound probe, a spinal needle was used to infiltrate the prostatic capsule. At this point a using a special trocar needle, 21 core biopsies were carried out of the prostate at the base, apex and mid portion of both Right and Left lobes.
The patient tolerated well the procedure. Mild urethral bleeding was observed. The patient was told to drink plenty of water for few hrs.
The biopsies were sent to pathology.
Thanks for any help you may be able to give. Still getting used to the new codes.