Question Transurethral resection of Urethral mass cpt?

Jessim929

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Hi everyone! I'm stumped as to what code to use on this procedure.
The dictation reads, in part, "A 21-French cystoscope was atraumatically placed into the meatus down to the region of the stricture which was just distal to the prostate. Also noted in this area was a large clot. This was dislodged using the scope and removed. This allowed me a better look at the noted papillary lesion in the urethra. At this time inspecting the region, the tissue appeared to be more scar tissue than likely a malignancy, but it was present and somewhat obstructing the lumen." Goes on to say "A 26-French resectoscope was atraumatically placed into the meatus and advanced down to the previously noted papillary lesion. In this region, I resected the mass with extreme care not to further injure the urethra. Small amount of chips and clots were sent for permanent pathologic evaluation."

I started at 53220, but it's unlikely a malignancy. Looked at 53200 but it was more than a biopsy. 52317 is out because it's not a stone. 52285 is a no because the patient is male. 52234 doesn't seem right because it wasn't in the bladder. And since there was cutting, 52214 doesn't fit because there was no destruction of tissue. 52204 doesn't seem like enough because it was more than a straight biopsy.

That's everything I can think of, and I'm probably overthinking it, but any other perspective would help. Thank you in advance!
 

liqgold2@aol.com

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Since TURB codes are included under the heading bladder and urethra in the CPT manual, use one of these codes for the urethral lesions/tumors resection as well. and by coding rules where bladder/urethral tumor size is not recorded, bill the smallest code...52224. Use diagnosis D49.59 as you await the pathology report. I hope this helps you. If you need further help, call me at 516-741-0118.
 
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