Urethrotomy with Foreign Body Removal?

toria11

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Location
Clearwater, FL
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Please see the OP note below. I'm thinking I may need to use an unlisted code? Maybe bench marked to 54115? Any help is very appreciated!

Procedure Performed
1. Cystoscopy with attempted removal of urethral foreign body sex toys 2. Perineal exploration with bulbous urethra urethrotomy and extraction of the foreign body

Type of Anesthesia
General

Indications
Urethral foreign body

Findings
Foreign body almost completely in the bladder the distal portion was in the bulbous urethra

Specimen(s)
Foreign body urethral sex toys
Technique/Description of Procedure
Patient was placed in the dorsal lithotomy position prepped and draped in the usual manner a 22 cystoscope was introduced into the urethra the foreign body was located in the bulbous urethra almost in the prostate and bladder. Attempts at removal with grasping forceps were unsuccessful as metal to metal it would not work.. We therefore then performed a perineal incision and exposed the bulbous urethra the bulbocavernosus muscles were opened. They were retracted laterally the bulbous urethral was located. A urethrotomy was then made with a Allis clamp we were able to grasp the foreign body and it was extracted it was 15 cm in length. Once this was done the urethra and the bulbocavernosus muscle were closed with 4 0 Vicryl interrupted sutures. After we had placed a 16 Foley catheter in the bladder. The skin was closed with staples and Dermabond. He was then transferred to recovery in stable condition
 
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I would suggest the following coding for your clinical scenario:
53010 for the perineal urethrotomy, opening and closing the perineal urethra. If the removal of the foreign body increased the time of the procedure and its complexity, I would also add modifier-22 to the above code. Reading the above report I do not believe it did. So I would not add the modifier.
 
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