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Thread: New to Urology HELP!

  1. #1

    Default New to Urology HELP!

    AAPC: Back to School
    Preoperative Diagnosis Abnormal imaging on CT scan of the abdomen.
    Postoperative Diagnosis Same
    Procedure CMG w abdominal Pressure Study, EMG, UPP, Cystourethroscopy

    Anesthesia Local anesthesia with 2% lidocaine urethral jelly (Urojet)
    Operative Findings No evidence of bladder mucosal tumor grossly.

    Specimen None
    EBL None
    Complications None

    CLINICAL HISTORY gentleman was noted to have filling defect in the bladder on CT scan of the abdomen. Patient is recommended to have cystoscopic examination.


    The patient was lying down in supine position on the operating table. The genitalia, upper thighs, and abdomen were prepped and draped in sterile manner. After this, genitalia, lower abdomen, and upper thighs were prepped and draped in sterile manner.
    2 % lidocaine jelly (Urojet) was instilled through the external urethral meatus, and after its adequate action for about 5 minutes, 16 French CYF5 Olympus flexible deflectable cystourethroscope was introduced through the external urethral meatus along the lumen of the urethra into the bladder. Inside of the urethra and bladder were visualized. Findings are as follows:

    Anterior urethra: Normal
    Area of external urethral sphincter: Normal
    Verumontanum: Normal.
    Posterior urethra: Elongated with enlargement of both lateral lobes and median lobe of the prostate gland.
    Bladder neck: Normal.
    Right ureteral orifice: Normal regarding its configuration and position with clear urinary efflux from the right ureteral orifice.
    Left ureteral orifice: Normal regarding its configuration and position with clear urinary efflux from the left ureteral orifice.

    All the bladder walls the dome and trigone were examined. The was no evidence of foreign body or calculus

    Bladder Mucosa: Normal
    Trabeculations: None
    Bladder diverticula: None
    Cellules: None

    After this the cystoscope was withdrawn and urethral findings were reconfirmed. Patient was then brought back to supine position and was returned to the recovery room in satisfactory general condition.

    No evidence of bladder mucosal tumor grossly.

    Follow up prn.
    Last edited by ASC CODER; 02-22-2010 at 05:28 PM.

  2. #2


    I was hoping for some info on the guidlines for coding urology, Just so I know this is going out right. Please!

  3. #3


    Are looking for a code for this service? It is 52000.

  4. #4


    thank you

    Just have not done urology and was unsure any tips and or sites you can give me would be helpful.

    Thanks again

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