I am having difficulty coding this op note. Please offer your suggestions as to what ICD-9 codes and CPT codes you would use. To give some background, this patient came in for a hysterectomy previously and had her bladder lacerated and it was repaired with sutures. The path report states: suture granuloma in the findings of the resection.
Post Op Dx: Foreign body in the bladder.
Porecedure Performed: Cystoscopy with bilateral retrograde pyelograms and resection of foreign body.
Op Note:
The patient was given IV sedation and put in dorsolithotomy position where she was prepped and draped in the usual manner. A 2% Xylocaine jelly was instilled into the urethra as topical anesthetic after which a 23 French cystoscope was introduced into the bladder. Inspection of the urethra revealed good coaptation of the urethral mucosa with healthy urethra with no strictures or diverticula. Inspecion of bladder revealed a large 3 cm round bladder stone. The dome of the bladder was well healed. There were absorbable stitches that were still present, but did not appear to be a nidus for infection or stones. There was a papillary lesion also noted in the right trigone. Using 5 French EHL the stone would not break up and was found to be soft and proteinaceous and tissue rather than bladder calculi and therefore 25.6 French continuous flow laser resectoscope with 24 French loop was then inserted into the bladder and using resectoscope the bladder lesion noted in the right trigone was removed. The area was fulgurated with hemostasis and then this bladder foreign body was resected with resectoscope and pieces were removed and evacuated. Once all pieces were removed hemostasis was controlled and a 20 French Foley catheter was inserted with 10 cc balloon. The patient went to Recovery Room in good condition and tolerated the procedure well.
Here is what I was thinking for ICD-9:
998.89 Other specified complicaion of procedures, not elsewhere classified
9390 Foreign body in bladder and urethra
E8788 Ohter surgical operation, with abnormal reaction/no surgical misadventure
E8499 Injury occuring at unspecified place
7015 Abnormal granulation tissue
5968 Disorder of bladder
What about these for the CPT codes:
Cystoscopy w/removal of stone?
Cystoscopy w/excision of a bladder lesion?
Cystoscopy w/pyelogram?
Post Op Dx: Foreign body in the bladder.
Porecedure Performed: Cystoscopy with bilateral retrograde pyelograms and resection of foreign body.
Op Note:
The patient was given IV sedation and put in dorsolithotomy position where she was prepped and draped in the usual manner. A 2% Xylocaine jelly was instilled into the urethra as topical anesthetic after which a 23 French cystoscope was introduced into the bladder. Inspection of the urethra revealed good coaptation of the urethral mucosa with healthy urethra with no strictures or diverticula. Inspecion of bladder revealed a large 3 cm round bladder stone. The dome of the bladder was well healed. There were absorbable stitches that were still present, but did not appear to be a nidus for infection or stones. There was a papillary lesion also noted in the right trigone. Using 5 French EHL the stone would not break up and was found to be soft and proteinaceous and tissue rather than bladder calculi and therefore 25.6 French continuous flow laser resectoscope with 24 French loop was then inserted into the bladder and using resectoscope the bladder lesion noted in the right trigone was removed. The area was fulgurated with hemostasis and then this bladder foreign body was resected with resectoscope and pieces were removed and evacuated. Once all pieces were removed hemostasis was controlled and a 20 French Foley catheter was inserted with 10 cc balloon. The patient went to Recovery Room in good condition and tolerated the procedure well.
Here is what I was thinking for ICD-9:998.89 Other specified complicaion of procedures, not elsewhere classified
9390 Foreign body in bladder and urethra
E8788 Ohter surgical operation, with abnormal reaction/no surgical misadventure
E8499 Injury occuring at unspecified place
7015 Abnormal granulation tissue
5968 Disorder of bladder
What about these for the CPT codes:
Cystoscopy w/removal of stone?
Cystoscopy w/excision of a bladder lesion?
Cystoscopy w/pyelogram?