Question

Code the following operative reports assigning the appropriate CPT codes(s) and any applicable modifiers.

PREOPERATIVE DIAGNOSIS: Bladder lesions with history of previous transitional cell bladder carcinoma.

POSTOPERATIVE DIAGNOSIS: Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.

OPERATION PERFORMED: Cystoscopy, bladder biopsies, and fulguration.

ANESTHESIA: General.

INDICATION FOR OPERATION: This is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy. He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules. He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months. Recent cystoscopy raises suspicion of another recurrence.

OPERATIVE FINDINGS: The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder. Scarring was noted along the base of the bladder from the patient's previous cysto TURBT. Ureteral orifice on the right side was not able to be identified. The left side was unremarkable.

DESCRIPTION OF OPERATION: The patient was taken to the operating room. He was placed on the operating table. General anesthesia was administered after which the patient was placed in the dorsal lithotomy position. The genitalia and lower abdomen were prepared with Betadine and draped subsequently. The urethra and bladder were inspected under video urology equipment (25 French panendoscope) with the findings as noted above. Cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area. Each of these biopsy sites were fulgurated with Bugbee electrodes. Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear. The patient's bladder was then emptied. Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area. There were no apparent complications, and the patient appeared to tolerate the procedure well. Estimated blood loss was less than 15 mL.

Answer 1

The procedure done here to visualize the urinary collecting system with a cystoscope passed through the urethra and bladder is known as cystourethroscopy, and fulguration is the electric current that destroys the tissue and panendoscope used here is a advanced cystoscope fitted with an obliquely forward telescope system that permits wide angle viewing of the interior of the urinary bladder (cpt code for this is 52000) , to code this more pricisely the lesion size is to be noted, the guidlines for coding as per cpt is code range from 52234 to 52240 the code is selected based on the the size of the lesion .