Incision and drainage of subcutaneous abscess of the penis. Procedure code:

Under direct visualization, the surgeon performed a drainage ureterotomy. Procedure code:

The patient’s insurance has changed, and she must change to a different OB/GYN physician. Thefirst physician has provided five visits. How will the services for the first physician be coded?  Procedure code:

Operative Report PREOPERATIVE DIAGNOSIS: Multiple bladder stones PROCEDURE: Cystoscopy for removal of stones INDICATIONS: This 58-year-old patient was found to have several bladder stones. He was here today for removal of those stones. The patient was voiding well currently. Informed consent was signed, and risks and benefits were explained and understood by the patient prior to the procedure. He agreed to proceed. DESCRIPTION OF PROCEDURE: The patient was taken to the cystoscopy suite and placed in the dorsal lithotomy position after adequate induction of general anesthesia. Levofloxacin 500 mg was given intravenously, preoperatively. The perineum and genitalia were prepped and draped in the usual sterile fashion. A 21-French cystourethroscope was inserted into the urethra, and the prostate was visualized. He did have some lateral lobe hyperplasia of the prostate, but otherwise no significant pathology in the urethra. The bladder was then entered and drained. Multiple bladder stones were seen, and these were all less than 0.5 cm apiece. The bladder stones were evacuated using cystoscope and irrigation with the Ellik evacuator. All stones were removed without difficulty. After the bladder was drained and all the stones were removed, the patient was awakened. He returned to the recovery room in satisfactory condition. Procedure code:

Laparoscopic Burch colposuspension for stress incontinence Procedure code:

Operative Report PREOPERATIVE DIAGNOSIS: Perimenopausal bleeding; possible endometrial hypoplasia POSTOPERATIVE DIAGNOSIS: Perimenopausal bleeding PROCEDURES: Hysteroscopy; D&C SPECIMEN TO LAB: Endometrial curetting ESTIMATED BLOOD LOSS: Less than 5 mL DESCRIPTION OF PROCEDURE: The patient was taken to the OR and, under satisfactory general anesthesia, was examined and noted to have a normal-size uterus. No adnexal masses were noted. She was prepped and draped in the routine fashion, the speculum was placed in the vagina, and the anterior lip of the cervix was grasped with a single-tooth tenaculum. The uterus sounded to 8 cm and easily admitted a #21 K-Pratt, so no further dilation was necessary. A 12-degree hysteroscope was placed, using lactated Ringer’s as the distending medium, and the cervical canal was normal. The cavity revealed just fronds of tissue. There was tissue sticking out that did not have a particularly polypoid appearance. No other lesions could be appreciated that were polypoid. Curettage with a Milan curette, a serrated curette, and then polyp forceps revealed minimal tissue, and one piece of tissue of 5 mm was revealed that might be consistent with what was seen on the previous sonogram. The hysteroscope was then replaced. No other lesions could be appreciated, and the walls appeared smooth. At this time, the hysteroscope and tenaculum were removed. The tenaculum site was touched with silver nitrate. The bleeding was minimal at the end of the procedure. She was taken to the recovery room in satisfactory condition. Procedure code:

The OB/GYN physician delivers a baby via cesarean section. The physician has provided allobstetrical care prior to delivery and will continue to follow the patient for her postpartum care. Procedure code:

Operative Report POSTOPERATIVE DIAGNOSIS: Bladder neck contracture PROCEDURE: Vaporization of bladder neck contracture DESCRIPTION OF PROCEDURE: The patient was prepped and draped in the usual sterile manner. Anesthesia was administered, and the patient was placed in the lithotomy position. A cystoscope was introduced into the bladder and forced through the bladder neck contracture. A KTP laser was passed through the working channel of the cystoscope to vaporize the fibrous bladder neck contracture. The patient was sent to recovery in stable condition. Procedure Code:  

Operative Report PREOPERATIVE DIAGNOSIS: History of low-grade transitional cell carcinoma POSTOPERATIVE DIAGNOSIS: Same PROCEDURE: Flexible cystoscopy INDICATIONS: The patient was a 49-year-old male diagnosed with low-grade transitional cell carcinoma of the bladder. He was here today for his regular bladder tumor follow-up. DETAILS: The patient’s genitalia were prepped and draped in the typical fashion. 20 cc of 2 percent lidocaine jelly was instilled into the urethra. The anesthesia was given five minutes to set in. The 19-French flexible cystoscope was passed through the urethra into the bladder. Once inside the bladder, the entire bladder mucosa was evaluated. No lesions were identified. Both ureteral orifices were seen and found to be normal. At this point, the scope was removed. The patient will be called in three months for his next follow-up. Procedure code:

The patient is a 50 YO female.  Operative Note: The surgeon performed a cystoscopy with resection of a 4.0-cm bladder tumor. The procedure concluded with a steroid injection into the urethral stricture. First-Listed Diagnosis: Add’l Diagnosis: First-Listed Procedure: Add’l Procedure: