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Need help with op note

  1. Default Need help with op note
    Medical Coding Books
    I really hope someone can help me. I am new to urology coding.

    is it 52320 51102 and is the injection separately reportable (if so what code) or is it included?

    PROCEDURE PERFORMED: 1. Cystoscopy with abdominal incision for placement of suprapubic tube.51102
    2. Removal of small bladder stones with fragmentation of small bladder stones.

    A cystoscope carefully down the urethra and into the bladder. I visualized the entire urethra with no strictures. Prostatic urethra was short. He had no significant prostatic obstruction. It was not a very enlarged prostate. I entered the bladder, and inspected all areas. There was some edema on the
    posterior bladder wall consistent with catheter irritation. There were thin, friable stones that looked they were associated with chronic catheter. I used the scope to fragment these friable, thin, stones into multiple smaller fragments, then I irrigated them out of the bladder. These were likely forming on the catheter. Once these were broken up and irrigated out I drained the bladder, refilled it to capacity, removed the scope. I then placed a Lowsley retractor down the urethra and into the bladder. I retracted this downward, this brought the tip of this up into the suprapubic area. I then injected 0.25% Marcaine with epinephrine, approximately 18 cc, in this area, in the suprapubic area. I then made a small skin incision, then incised down through the anterior fascial wall on top of the Lowsley retractor. I made a small incision in the anterior abdominal fascia in the midline, and then incised the bladder on top of the Lowsley retractor. I then brought the Lowsley retractor through the bladder, through the anterior abdominal fascia, then through the skin. I then placed a 20 French silicone catheter into the jaws of the Lowsley retractor and then withdrew this back through the skin through the anterior abdominal fascia, then through the bladder wall. I then made sure the tube was positioned properly in the bladder, and then inflated it to 20 cc, placed this to a drainage bag. The scope was removed.
    Codegirl0422, CPC

  2. Default
    or is it 52310?
    Codegirl0422, CPC

  3. Default
    You should report it to 52310 for removal of stone from the bladder, CPT code 52320 is used to report removal of ureteral stone which is not the case here.

    Also, after reading the body of the report, it does not seems to be a suprapubic catheter placement placement procedure, rather it is a cystotomy procedure,The bladder was incised and a suprapubic tube was placed through the abdominal incision and was fitted for continued drainage of bladder. Read the report carefully.

    I feel the final codes should be 52310 and 51040.

    Hope it helps!

    Vinay Kumar CPC

  4. Default
    Thank you!
    Codegirl0422, CPC

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