Preoperative diagnosis: Bladder tumor, 3.4 cm
Postoperative diagnosis: Bladder tumor, 4.2 cm
Procedure: The patient was placed in the lithotomy position after receiving IV sedation. He was prepped and draped. A 21-French cystoscope was passed into the bladder; a previous CT scan of the bladder indicated a tumor of approximately 3.4 cm. After inspection of the bladder with the cystoscope, the findings were consistent with a bladder tumor but the size was inconsistent; the actual finding was a size of 4.2 cm. A biopsy was taken, and laser surgery was performed with fulguration on the removal of the tumor. The patient tolerated the procedure well.
Code only the procedure:

Question

Quizplus · Accepted Answer

The correct procedure code is 52235, which corresponds to cystourethroscopy with fulguration (including cryosurgery or laser surgery) and/or resection of; medium bladder tumor(s) (2.0 to 5.0 cm). This code accurately describes the procedure performed, which involved the use of a cystoscope for inspection and laser surgery for the removal of a bladder tumor measuring 4.2 cm.

Preoperative Diagnosis: Bladder Tumor, 3.4 Cm