52310 or 52315?

toria11

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Location
Clearwater, FL
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Hi! Would 52315 be appropriate for this procedure? The patient had an encrusted ureteral stent, the stent was removed and the encrustations fell off into the bladder and needed to be crushed in order to be removed. Thanks for your help!

Indication for operation: Patient with bilateral stents with attempted removal in the
office. One stent could be removed with a second stent had encrustation on the distal curl that
prevented it from being removed.
Preop diagnosis: Retained foreign body
Postoperative diagnosis: Same
Findings: The remaining double-J ureteral stent was removed without issues. Encrustations on
the ureteral stent was removed.
Specimens: None
Drains: None
Operation performed: Cystoscopy with removal of foreign bladder body
Description of operation: After informed consent was obtained, the patient was brought back to
operating room and underwent general IV sedation. She was placed in the low lithotomy position.
Her genitalia was prepped and draped in a sterile surgical manner. A time-out was performed.
A 22 French rigid cystoscope was inserted into the urethra advanced to the bladder. The
remaining ureteral stent was identified. The encrustations from the ureteral stent had now fallen
off and was in the bladder. The ureteral stent was removed and discarded. The encrustations
required graspers to break up the encrustations /stone in order to remove it. All stones and
calcifications were removed from the bladder. Bladder was emptied. Patient was returned to
supine position, and taken to recovery room stable condition.
 
Messages
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I would suggest the following coding for your clinical scenario:
52318 for the crushing and removal of several stones
52310-XS for removal of the single stent
 
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