What code sets would be reported for this encounter

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Reference no: EM134018798

Assignment:

This is an 83-year-old white female with a three-month history of microscopic hematuria, which was asymptomatic. Patient has been followed by her family physician. He prescribed antibiotics but the problem is unresolved. The patient does not have a history of urinary tract infections and has never experienced hematuria prior to this episode. Patient had an IVP earlier today which disclosed relatively normal upper urinary tracts but some filling defects in the urinary bladder. Her current medications include iron supplements, and one baby aspirin daily.

Allergies: NKA

Past Surgical/Medical History: Patient has had three normal pregnancies and two spontaneous abortions completed by dilation and curettage. The patient has a history of bunionectomy and comminuted wrist fracture following a fall several years ago. Generally, she is in good health.

Social/Personal History: Patient neither smokes nor drinks. She does consume several cups of caffeine each day in the form of coffee and hot tea.

Family History: Unremarkable from a urological standpoint.

Review of System: The ROS is unremarkable. The patient denias weight losing weight gain no shortness of breath or chest pain. No change in bowel habits, or naisea nausea or vomiting.

Technique: The patient was placed in the modified dorsolithotomy position, prepoed and draped in the usual manner. General anesthesia was attained. A urethroscopy was carried out with Foroblique lens.

A 28-French resectoscope sheath with obturator was inserted into the bladder. Transurethral resection of the approximately 2.1-cm bladder tumor was performer carcinoma, fulguration of the surrounding bladder mucosa was performed Instruments were withdrawn and a 20-French Foley catheter inserted. The patient was transported to PACU in stable condition.

Pathology Report

Tissue Submitted: Bladder tumor

Gross Findings: Received in formalin and labeled with the patient's pisorders of the Musculoskeletal system and Connective Tissue

What code sets would be reported for this encounter?

Reference no: EM134018798

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