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Cystourethroscopy with biopsy

  1. #1
    Default Cystourethroscopy with biopsy
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    When the surgeons performs a cystourethroscopy with biopsy of a "suspicious area" (fistula in this case) not a definate tumor or lesion and also utilizes fulguration for cauterization would this be most appropriately coded as 52204?? Or if we queried the surgeon for the size of the area could we utilize the 52224 - 52240 range or are these codes specific to lesions? I have attached a portion of the operative report below.

    I would appreciate any feedback

    op note
    Bladder was drained and refilled, and the biopsies were performed at the area of the fistula, three-quarters were obtained and then sent for permanent section. I used the rigid cold cup biopsy forceps. There was some bleeding for one of these, so that was cauterized with a Bugbee electrode.
    Last edited by nbrau; 08-18-2010 at 12:55 PM.

  2. Default
    Fistula without any other lesion. Biopsy taken. Cauterization done for the bleeder nor for fulgrating the lesion tissues. "When the secondary procedure reguires significant adtional timean deffort, may be identified by Mod-22".
    So the ideal code is 52204 only and can be appended with modifier.
    The codes 52224-52240 can not be used in this case because they all need fulguration with cryosurgery, or laser surgery and /OR resection of; . What he did was just an electric cautery for stopping the bleeder.
    Last edited by preserene; 08-18-2010 at 02:26 PM.

  3. #3
    Default
    That makes perfect sense. Thank you for clarifying this for me

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