Urolift and bladder stone removal at the same time

AgnieszkaMarek

Contributor
Messages
22
Location
Glesns Falls, NY
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PREOPERATIVE DIAGNOSIS:
BPH with obstruction, bladder stones
POSTOPERATIVE DIAGNOSIS:
Same
PROCEDURE:
Cystoscopy, removal of bladder stones
Prostatic urethral lift (4 implants)

Moderate BPH, trabeculated bladder
Few small bladder stones (4 stones, 3-4 mm each)
INDICATIONS:
Mr. Lester is a 70-year-old gentleman with moderate BPH symptoms despite medical therapy. Cystoscopy in the office revealed moderately enlarged prostate, and several bladder stones in the base of the bladder. He had mild to moderate intravesical protrusion and moderate trabeculation of the bladder. Risks, benefits, and alternatives were discussed with the patient and he elected to proceed to the operating room for cystoscopy, removal of bladder stones, and prostatic urethral lift at this time.
DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was brought to the operating room suite and placed in the supine position on the operating room table. He had received antibiotics for prophylaxis preoperatively. Monitored anesthesia care was induced and he was repositioned in the dorsal lithotomy position.
His external genitalia were prepped and draped in the standard sterile fashion. The Urolift cystoscope was inserted per urethra and navigated to the bladder with the visual obturator and 0° lens. His anterior urethra was normal. His prostatic urethra was noted to have moderate bilobar hypertrophy, no median lobe. The bladder was inspected circumferentially and was noted to be without lesions, tumors. However, there were several stones in the base of the bladder measuring 4 mm each. The obturator was removed from the scope, and the stones were able to be removed directly through the scope itself.
The visual obturator was then removed and the Urolift suture deployment device was inserted through the cystoscope sheath. Starting at 1.5 cm distal to the bladder neck on the left side, the first Urolift suture was deployed per documented technique. This appeared to result in good tissue compression of the lateral lobe on the left side. In similar fashion, a second suture was placed 1.5 cm distal to the bladder neck on the right side. Additional sutures were then placed distal to the first sutures in order to achieve good tissue compression. A total of 4 sutures were placed in total between the bladder neck and the verumontanum. At the end of the procedure, there was a good channel visible with bladder empty and water off. There was minimal bleeding from the prostatic urethral mucosa.
The decision was made to give him a voiding trial. The bladder was moderately filled, and the scope was removed. Urojet was placed per urethra for local anesthesia. The patient was awoken and transferred to ambulatory surgery in good condition. He tolerated the procedure very well.


THIS IS MEDICARE PATIENT
I'd use C9740 and 52310 , however I'm getting edit that I can't have these two coded together. Any suggestions ?
 

RebeccaB

Guru
Messages
169
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0
We bill the Urolift as ..52441 x 1 unit (1st implant), 52442 x3 units (2-6 implants)
52310 for the bladder stone is bundled

Rebecca
 
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