Forum - Questions & Answers

Apr 3rd, 2014 - rossella40

Cryoablation of the prostate with Cystoscopy

Hello,
I need some help coding a cryoablation of prostate cancer with cystoscopy. I would code 55873 for the cryoablation, but I am not sure if the cystoscopy would be included or if it needs to be coded separate. Following is the op note:

The patient was brought to the operating room and general anesthesia was induced to a satisfactory level. He received preoperative IV gentamicin. He was positioned in the dorsal lithotomy position, and the genitalia was prepped with Betadine paint. This included the lower abdomen. A flexible cystoscopy was then done and the prostate and the large median lobe was evident. The bladder was filled and a stab wound was placed in the pubis, and the 16-French large trocar was then positioned and the peel-away sheath removed. The 16-French Foley catheter was placed and clamped. The transrectal ultrasound probe was then positioned and measurements were done as noted above. The median lobe was evident. The cryoprobes were then placed in the posterior row. The mid posterior was a separate channel, channel 4. This was then extended to 3 probes in the mid level area away from the urethra, approximately 5 mm. Four probes were then placed anteriorly encircling the anterior border of the prostate. Repeat cystoscopy was done, and there was no evidence of prostatic fossa entries. The 0.036 Glidewire was then placed into the bladder and the scope removed. The urethral warmer was then positioned and urethral warming continued at 43 degrees centigrade.

Thank you!
Rossella



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