Urology Coding Alert

How would you report this procedure?

Test your operative report interpretation skills with this case study from a Urology Coding Alert subscriber in Springfield, Ill.

Indication: Patient has history of a neobladder with a stone in distal right ureter. He had a previous stent placed. He had a right PCN access placed yesterday.

Operative Procedure: Patient prepped and flexible cystourethroscopy was performed. Bladder neck was open and the neobladder was inspected -- no stones in the neobladder. I could not identify the stent in the neobladder. I placed a 16F. coude-tipped catheter.

Patient turned prone. Right flank prepped. Radiologist came in and placed working access port. He placed a glidewire down into the neobladder. Rigid renal endoscopy and ureteroscopy performed antegrade. Right renal pelvis and proximal and distal ureter normal, no stones seen. I was able to go right into the neobladder to see the Foley tip balloon. Scope passed twice up and down, no stone seen. I irrigated Foley. Radiologist came in and removed right stent. He also performed the nephrostogram and placed a right PCN tip 14 French catheter. He will dictate that.

How would you code this procedure?

Answer: You should report the following codes for this case:

• Report 50951 (Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) for the antegrade ureteroscopy. Attach diagnosis code 592.1 (Calculus of ureter).
• Report 50551 (Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service) for the nephroscopy. Again, use diagnosis code 592.1.
• Report 44385 (Endoscopic evaluation of small intestinal [abdominal or pelvic] pouch; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the pouchoscopy. Attach diagnosis code 936 (Foreign body ... stone ... in intestine and colon).
• Report 52000 (Cystourethroscopy [separate procedure]) for the urethroscopy. Append modifier 52 (Reduced services) because the urologist did not perform a complete cystoscopy. Use 594.2 (Calculus in urethra). Additionally, because no stones were visualized, add V65.5 (Feared condition[s] not demonstrated).

Bonus: Want your complicated operative report featured in Code This!? Send it to editor, Leesa A. Israel, at leesai@codinginstitute.com.