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Cysto question

  1. #1
    Location
    Bristol VA
    Posts
    22
    Default Cysto question
    Medical Coding Books
    The physician states in his op report:
    "Cystoscopy revealed a normal bladder mucosa without evidence of recurrent tumor. The right ureteral orifice was along the right side of the interureteric ridge. On the left side of the interureteric ridge there was obvious scarring and crystallization over the left ureteral orifice with tight obstruction. Attempts at passing a guidewire or a ureteral access catheter of this obstructed ureteral orifice was impossible. Using the 26 French resectoscope the left ureteral tunnel was resected in hopes of exposing an opening of the tunnel. After taking at least 4 specimens of tissue along the left ureteral tunnel no obvious ureteral orifice could be identified. At one point the ureteral access catheter went up what appeared to be a tunnel and a RG/PG was performed but this showed no evidence of the ureter so this was in a false passage and further attempts were abandoned."

    The physician wants a 52235, but since no tumors were removed I say no. I thought of the 52341 with a 53 mod, but really am not sure about this one. Any help is appreciated!

    Thank you!
    Amy Chapman Suiter, CPC, CPMA
    President - Bristol VA Local Chapter - 2010
    President - Kingsport TN Local Chapter - 2009
    President Elect - Kingsport TN Local Chapter - 2008

  2. Cool
    Quote Originally Posted by amycs View Post
    the physician states in his op report:
    "cystoscopy revealed a normal bladder mucosa without evidence of recurrent tumor. The right ureteral orifice was along the right side of the interureteric ridge. On the left side of the interureteric ridge there was obvious scarring and crystallization over the left ureteral orifice with tight obstruction. Attempts at passing a guidewire or a ureteral access catheter of this obstructed ureteral orifice was impossible. Using the 26 french resectoscope the left ureteral tunnel was resected in hopes of exposing an opening of the tunnel. After taking at least 4 specimens of tissue along the left ureteral tunnel no obvious ureteral orifice could be identified. At one point the ureteral access catheter went up what appeared to be a tunnel and a rg/pg was performed but this showed no evidence of the ureter so this was in a false passage and further attempts were abandoned."

    the physician wants a 52235, but since no tumors were removed i say no. I thought of the 52341 with a 53 mod, but really am not sure about this one. Any help is appreciated!

    Thank you!
    first of all, 52235 is not correct as fulguration is not mentioned, and it is for resection of tumors of the bladder. This op note does not state that the stricture was due to a tumor. It indicates the stricture is from scarring. If the doctor insists it was a tumor that was causing the stricture then 52355 would be more appropriate for the ureter.

    I am going to side with you, not the physician, with code 52341-53 as the attempt at passing the guidewire thru this stricture was not possible and the rest of the procedure was aborted.
    Last edited by capricew; 12-02-2010 at 10:11 PM. Reason: more text

  3. Default
    How about 52290- Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral

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