Please help me determine if the attached operative note justifies the coding of 55700, 76872, 76942-59. If not, what documentation is missing?
We are billing for the facility on this.
Preoperative Diagnosis: Prostate cancer.
Postoperative Diagnosis: Prostate cancer.
Procedure Performed: Ultrasound-guided prostate needle biopsy.
Anesthesia: MAC. IV Fluids: 500 mL.
Estimated Blood Loss: None.
Drains: None.
Specimen: Twelve core prostate needle biopsy.
Condition: Stable.
Description of Procedure: After risks and benefits were explained to the patient including the risks of bleeding, infection, injury to the rectum or prostate, with chance of pain, infection, need for hospitalization due to sepsis, chance of missing cancer or need for future intervention, the patient signed consent and was taken to the operating room. After confirming, he got IV antibiotics, underwent MAC anesthesia, and was placed in the right lateral decubitus position and prepped and draped in standard surgical fashion.
Transrectal ultrasound probe was inserted into the rectum under ultrasound guidance with adequate lubrication. Then, 10 mL of lidocaine was injected to the neurovascular bundles. After this, 12-core biopsy was performed taking 6 cores from the right and 6 cores from the left including the medial and lateral aspects of the mid, base, and apex. Each specimen was sent off the table for pathologic evaluation. The probe was then held against the rectum for 5 minutes for hemostasis and removed. Minimal bleeding was noted.
The patient was awakened from anesthesia and transferred to the recovery room in stable condition. Plan for the patient is to follow up my office in 2 weeks to review his pathology.
I appreciate any help on this.
Cheryl
We are billing for the facility on this.
Preoperative Diagnosis: Prostate cancer.
Postoperative Diagnosis: Prostate cancer.
Procedure Performed: Ultrasound-guided prostate needle biopsy.
Anesthesia: MAC. IV Fluids: 500 mL.
Estimated Blood Loss: None.
Drains: None.
Specimen: Twelve core prostate needle biopsy.
Condition: Stable.
Description of Procedure: After risks and benefits were explained to the patient including the risks of bleeding, infection, injury to the rectum or prostate, with chance of pain, infection, need for hospitalization due to sepsis, chance of missing cancer or need for future intervention, the patient signed consent and was taken to the operating room. After confirming, he got IV antibiotics, underwent MAC anesthesia, and was placed in the right lateral decubitus position and prepped and draped in standard surgical fashion.
Transrectal ultrasound probe was inserted into the rectum under ultrasound guidance with adequate lubrication. Then, 10 mL of lidocaine was injected to the neurovascular bundles. After this, 12-core biopsy was performed taking 6 cores from the right and 6 cores from the left including the medial and lateral aspects of the mid, base, and apex. Each specimen was sent off the table for pathologic evaluation. The probe was then held against the rectum for 5 minutes for hemostasis and removed. Minimal bleeding was noted.
The patient was awakened from anesthesia and transferred to the recovery room in stable condition. Plan for the patient is to follow up my office in 2 weeks to review his pathology.
I appreciate any help on this.
Cheryl