Stacy1996
Contributor
Hi
I am little bit confuse selecting a code for prostate resection I think it could be 52601 or 52648 below is the operative report. Please help.
DESCRIPTION OF PROCEDURE: He was placed in the supine position. Anesthesia was administered without complication. A proper timeout was held and IV antibiotics administered. He was placed in the dorsal lithotomy position and prepped and draped in sterile surgical fashion. The urethra was serially calibrated from 20-30 French using the Van Buren urethral sounds. The Olympus 26 French resectoscope sheath with 30-degree lens and visual obturator was advanced into the patient's urethra. The penile and bulbar urethra appeared grossly normal. He had lateral lobe coaptation and elevated bladder neck. Both ureteral orifices appeared grossly normal. The obturator was then exchanged for the bipolar Iglesias resectoscope. The median lobe was resected followed in turn by the left lateral lobe, right lobe and finally the anterior prostate. The button was used to vaporize remaining tissue and for cautery. The verumontanum was identified and protected. At no time did the resection extend distal to the verumontanum, and at no time was there any evidence of a capsular tear, penetration, or disruption of the bladder neck. Once all prostate chips were evacuated from the bladder and all blood clots were evacuated from the bladder, the patient's bladder was left full. The bilateral ureteral orifices were identified and intact. The scope was removed. A 22 French 3-way Coude catheter was advanced into the bladder without any difficulty and drained. Hand irrigation was performed to confirm adequate hemostasis and correct position of the catheter. The balloon was then inflated with 30 ml of sterile water. All chips were sent to pathology for permanent section. Continuous bladder irrigation was initiated. The patient was placed in the supine position. Anesthesia was reversed. He was transferred to the PACU in stable condition.
Any input can help.
Thank you
I am little bit confuse selecting a code for prostate resection I think it could be 52601 or 52648 below is the operative report. Please help.
DESCRIPTION OF PROCEDURE: He was placed in the supine position. Anesthesia was administered without complication. A proper timeout was held and IV antibiotics administered. He was placed in the dorsal lithotomy position and prepped and draped in sterile surgical fashion. The urethra was serially calibrated from 20-30 French using the Van Buren urethral sounds. The Olympus 26 French resectoscope sheath with 30-degree lens and visual obturator was advanced into the patient's urethra. The penile and bulbar urethra appeared grossly normal. He had lateral lobe coaptation and elevated bladder neck. Both ureteral orifices appeared grossly normal. The obturator was then exchanged for the bipolar Iglesias resectoscope. The median lobe was resected followed in turn by the left lateral lobe, right lobe and finally the anterior prostate. The button was used to vaporize remaining tissue and for cautery. The verumontanum was identified and protected. At no time did the resection extend distal to the verumontanum, and at no time was there any evidence of a capsular tear, penetration, or disruption of the bladder neck. Once all prostate chips were evacuated from the bladder and all blood clots were evacuated from the bladder, the patient's bladder was left full. The bilateral ureteral orifices were identified and intact. The scope was removed. A 22 French 3-way Coude catheter was advanced into the bladder without any difficulty and drained. Hand irrigation was performed to confirm adequate hemostasis and correct position of the catheter. The balloon was then inflated with 30 ml of sterile water. All chips were sent to pathology for permanent section. Continuous bladder irrigation was initiated. The patient was placed in the supine position. Anesthesia was reversed. He was transferred to the PACU in stable condition.
Any input can help.
Thank you