81. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate. POSTOPERATIVE DIAGNOSIS: History of adenocarcinoma...

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81. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate. POSTOPERATIVE DIAGNOSIS: History of adenocarcinoma...

81. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate.
POSTOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate.
PROCEDURES PERFORMED:
1. Transrectal ultrasound performance with:
2. Volume study.
3. Needle localization.
4. Needle implantation.
5. Cystoscopy.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal. PROCEDURE: Please see the preoperative note for indications of the procedure, as well as full informed consent. The patient underwent a general anesthetic and was put in the extended dorsal lithotomy position. The table was decanted or in Trendelenburg 5 degrees. He was prepped and draped in the usual fashion, which included a 14-French Foley catheter with 120 ml of sterile saline in his bladder. The testicles and scrotum had been taped back and away. We irrigated the rectum with sterile saline, performing a pseudo-enema. The patient underwent transrectal ultrasound placement. This was connected to the gantry. The placement of ultrasound and the grid work were set up so that the base of the prostate is noted at #1 on the grid work. The anterior most component at approximately 4.5–5, prostate extended from side-to-side from A to F.
   Five-mm increment imaging slices were obtained, starting at the base of the prostate, carrying it back for a total of 3 cm to 30. Volume of the prostate is approximately 33 ml.
   The outline of the prostate was drawn during the volume study. This information was given to the computer electronically so that a plan could be developed. Once the plan had been completed, the placement of the needles was performed in the usual fashion. The dose was delivered via 125 seeds after placement of the needles.
   The total number of needles was 41 for 107 seeds (radioelements) placed with ultrasound guidance. The patient tolerated this well. At the conclusion, the patient was re-prepped and draped with the Foley catheter being removed and a cystoscopic evaluation was performed. There is no evidence of perforation of the urethra, bladder neck, or bladder. Urine within the bladder was clear. No seeds or spacers could be identified. An 18-French Foley catheter was then placed along with Triple antibiotic salve to the perineum and mesh panties. He tolerated the procedure well overall. Estimated blood loss minimal.
CPT Code(s):

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Answer 1

Answer #1

Answer: The CPT codes are mainly used by the healthcare professionals to code the procedures. These codes can be further used for the reimbursement process.

The CPT codes are:

Transrectal ultrasound performance -76872
Volume study.- 76873
Needle localization.- 55700
Needle implantation. - 55876
Cystoscopy - 52000

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Answer 2

81. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate. POSTOPERATIVE DIAGNOSIS: History of adenocarcinoma...

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81. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate. POSTOPERATIVE DIAGNOSIS: History of adenocarcinoma...

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