mnmd9488
Contributor
Hi, I have a pt that has 2 ureters (duplicated collecting system) on the right side. The dr is doing a stone extraction in both ureters on the same side. I am not sure if I should use a 50 mod because that would mean right and left. Technically pt has 2 ureters on right side. Would modifier 22 work with this or is there something else that I can add. The surgeon wants to bill 52353-50 ; 52320-rt x2.
POSTOPERATIVE DIAGNOSES:
1. Right hydroureteronephrosis in a completely duplicated system due to
a 1 cm right proximal ureteral stone.
2. Acute right pyelonephritis, resolved.
PROCEDURE PERFORMED:
1. Cystoscopy.
2. Ureteroscopy x2 in a complete duplicated right ureteral system.
3. Right retrograde pyelogram.
4. Removal of right ureteral stents.
5. Stone basketing of the stone obstructing the proximal ureter of the
lower pole of the kidney right side in a completely duplicated system.
OPERATIVE FINDINGS: Under anesthesia, abdominal examination normal.
Pelvic exam normal. Cystoscopy showed two ureteral stents with a stone
in the proximal ureter. On retrograde pyelogram it is unclear in which
ureter the stone was present. Hence, I performed initially upper pole
ureteroscopy where it appeared fairly clean with no definite stone.
Then I performed a lower pole ureteroscopy that showed a 1 cm stone that
was impacted in the proximal ureter. The site of impaction was almost
like a pouch and dilated with significant inflammation. There was no
significant infection. The urine was clear proximal to this.
DESCRIPTION OF THE PROCEDURE: After obtaining informed consent. After
clearance by Anesthesia and internist, the patient was taken to the OR.
Under general anesthesia, the patient was positioned in the gentle
lithotomy position. A surgical timeout was performed. The area was
prepped and draped. I visualized the two ureters that were separately
stented. Then I used the upper pole ureter by recognizing the medial
location of the ureter opening (Wigart-Meyer law). I introduced a
guidewire into the upper pole, following the location of the ureteral
opening which was more medial in the trigone. Then that stent was
removed. I introduced a semi-rigid uteroscope and I was able to go all
the way up to the UPJ. Could not see any definite stone. It was
unclear to me whether the stone had migrated or it was in the lower
system. So, I took out the ureteroscope and I reintroduced the
cystoscopy. I introduced a second wire through the lower pole ureter
and the previous stent was removed. Then I reintroduced the
ureteroscope. I was able to go all the way up into the proximal ureter
of the lower pole ureter. I was able to localize the stone. Because of
the fear of migration proximally, I introduced a 1.8 basket. I was able
to entrap it and I was able to gently pull it out without much
difficulty at all as the ureter was dilated.
POSTOPERATIVE DIAGNOSES:
1. Right hydroureteronephrosis in a completely duplicated system due to
a 1 cm right proximal ureteral stone.
2. Acute right pyelonephritis, resolved.
PROCEDURE PERFORMED:
1. Cystoscopy.
2. Ureteroscopy x2 in a complete duplicated right ureteral system.
3. Right retrograde pyelogram.
4. Removal of right ureteral stents.
5. Stone basketing of the stone obstructing the proximal ureter of the
lower pole of the kidney right side in a completely duplicated system.
OPERATIVE FINDINGS: Under anesthesia, abdominal examination normal.
Pelvic exam normal. Cystoscopy showed two ureteral stents with a stone
in the proximal ureter. On retrograde pyelogram it is unclear in which
ureter the stone was present. Hence, I performed initially upper pole
ureteroscopy where it appeared fairly clean with no definite stone.
Then I performed a lower pole ureteroscopy that showed a 1 cm stone that
was impacted in the proximal ureter. The site of impaction was almost
like a pouch and dilated with significant inflammation. There was no
significant infection. The urine was clear proximal to this.
DESCRIPTION OF THE PROCEDURE: After obtaining informed consent. After
clearance by Anesthesia and internist, the patient was taken to the OR.
Under general anesthesia, the patient was positioned in the gentle
lithotomy position. A surgical timeout was performed. The area was
prepped and draped. I visualized the two ureters that were separately
stented. Then I used the upper pole ureter by recognizing the medial
location of the ureter opening (Wigart-Meyer law). I introduced a
guidewire into the upper pole, following the location of the ureteral
opening which was more medial in the trigone. Then that stent was
removed. I introduced a semi-rigid uteroscope and I was able to go all
the way up to the UPJ. Could not see any definite stone. It was
unclear to me whether the stone had migrated or it was in the lower
system. So, I took out the ureteroscope and I reintroduced the
cystoscopy. I introduced a second wire through the lower pole ureter
and the previous stent was removed. Then I reintroduced the
ureteroscope. I was able to go all the way up into the proximal ureter
of the lower pole ureter. I was able to localize the stone. Because of
the fear of migration proximally, I introduced a 1.8 basket. I was able
to entrap it and I was able to gently pull it out without much
difficulty at all as the ureter was dilated.