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April 24, 2015
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Code This!

Current Scenario Week of April 24, 2015:
View Answer From Last Scenario

Assign the appropriate ICD-9-CM diagnosis code(s), CPT procedure code(s), and HCPCS Level II code(s) for the following scenario:

Preoperative diagnosis: Prostate cancer, clinical stage T2a

Postoperative diagnosis: Prostate cancer, clinical stage T2a

Procedure performed: Cystoscopy with cryosurgical ablation of the prostate

Procedure: The risks and benefits of the procedure were again explained to the patient and his family, and informed consent was obtained. He was taken to the operating room. After adequate induction of general endotracheal anesthesia, he was placed in a dorsal lithotomy position. After performing flexible cystoscopy, a Foley catheter was inserted into the bladder. A transrectal ultrasonography (TRUS) probe was inserted into the rectum. The entire prostate was visualized by ultrasound and re-measured. The probe template was then positioned over the perineum and the template guide brought up on the ultrasound screen for needle placement guidance. Then 17-gauge needles were placed into the prostate, from an anterior to posterior direction. Five rows of needles were placed as follows: row #1: 3 needles; row #2 at the level of the mid-prostate: 4 needles; row #3 in the right lateral peripheral zone: 2 needles; row #4 urethra: 1 needle; and row #5 left lateral peripheral zone: 2 needles.

Ultrasound guidance demonstrated the needles were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra. The urethral warmer was passed into the bladder and flow initiated. The prostate was frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior. The ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself. Active warming was performed before refreezing the prostate again and then passively warming it back to room temperature. The urethral warmer was left on after removal of the needles. The patient tolerated the procedure well and was sent to the post anesthesia care unit in satisfactory condition.

Code this scenario with ICD-9-CM, CPT and HCPCS Level II codes.

 

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