AHA Coding Clinic® for HCPCS - 2024 Issue 4; Ask the Editor

Dilation of bladder neck contracture/stenosis with endoscopic balloon

A patient with prior history of radical prostatectomy presented with recurrent bladder neck contracture/stenosis. Under general anesthesia the patient was placed in low lithotomy position pressed and draped in the usual sterile fashion. A retrograde urethrogram was performed to delineate the anatomy. Next, a 22-French rigid cystoscope was inserted into the urethra and advanced to the level of the stenosis. A wire was placed across the stenosis into the bladder. It was unable to be adequately dilated with sounds. Next, the 30-French Optilume® balloon was advanced across the stenosis and inflated to its recommended maximum pressure, it was held there for 5 minutes and then deflated. A 16-French council catheter was then placed over the wired into the bladder. He was then extubated and transported to the recovery room in stable condition.How would the cystoscopy with endoscopic balloon dilation of bladder neck contracture/stenosis be coded? ...

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