Jody Mortensen
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I need help in determining what CPT codes to assign for the procedure below. Can I give the urologist's 52276 for the cystourethroscopy with direct vision internal urethrotomy, 51610 for the injection for the retrograde urethrogram & 74450 for the retrograde urethrogram? The radiologist did not interpret the urethrogram. If the surgeon dictates findings in the op note of the urethrogram does this suffice for the 74450 assignment or is a seperate report needed? I'm thinking I don't need a 26 modifier on the 74450 because our facility owns the equipment? Any help or direction would be greatley appreciated. I have gone to the AUA website but not real confident with the DI portion.
Please read the following op note: dx/urethral stricture
Patient taken to OR, he was placed in modified left decubitus position. A retrograde urethrogram with fluoroscopy was performed. He had approximately 1 cm narrow urethral stricture & normal caliber urethra again until in the bulbar urethra I encountered a shorter, but tighter urethral stricture thatn the 1 that was in the pendulous urethra. He was placed in the dorsolithotomy postion, I placed the urethrotome into the urethra under direct vision & encountered the the pendulous urethral stricture. I placed a guidewire through the scope as a safety wired, but went only through the first stricture. I used the cold knife to incise this stricture & then came to the bulbar urethral stricture. I had to use a glidwire to place it through the stenotic urethral opening. I then used the cold knife again to incise the stricture. I then was able to see past it toward the bladder neck. The ureterotome was taken off the wire & replaced with 17 French cystoscope. It was placed per urethra into the bladder, no lesion or foreign bodies seen. The scope was removed off of the wire & 18 French Councill catheter was placed per urethra.
Long but hopefully someone can help?
Thank you
Jody Hecht
Please read the following op note: dx/urethral stricture
Patient taken to OR, he was placed in modified left decubitus position. A retrograde urethrogram with fluoroscopy was performed. He had approximately 1 cm narrow urethral stricture & normal caliber urethra again until in the bulbar urethra I encountered a shorter, but tighter urethral stricture thatn the 1 that was in the pendulous urethra. He was placed in the dorsolithotomy postion, I placed the urethrotome into the urethra under direct vision & encountered the the pendulous urethral stricture. I placed a guidewire through the scope as a safety wired, but went only through the first stricture. I used the cold knife to incise this stricture & then came to the bulbar urethral stricture. I had to use a glidwire to place it through the stenotic urethral opening. I then used the cold knife again to incise the stricture. I then was able to see past it toward the bladder neck. The ureterotome was taken off the wire & replaced with 17 French cystoscope. It was placed per urethra into the bladder, no lesion or foreign bodies seen. The scope was removed off of the wire & 18 French Councill catheter was placed per urethra.
Long but hopefully someone can help?
Thank you
Jody Hecht