Bernadette10
Guru
Is this enough documentation to bill 52330-RT with 52332-RT? Can the guidewire be considered "an instrument?"
Indications:
This is a 63 y.o. male with a 4-5mm RT proximal ureteral stone in the setting of low grade fever.
The patient was brought to the operative suite and placed in the supine position and general anesthesia administered before repositioning in dorsolithotomy with adequate padding. The genitals were prepped and draped in normal sterile fashion. A 22 French rigid cystoscope was subsequently passed per urethra into the bladder. The urethra appeared normal with mild lateral lobe coaptation of the prostate and no bladder neck elevation. Once in the bladder, the urothelium was inspected with no lesions seen.
The RT ureteral orifice was identified and cannulated with a guidewire. A 5 French catheter was passed into the intramural tunnel. The guidewire was then passed through the yellow catheter to the level of the kidney after manipulating the stone so that the wire could pass beyond it. Pollick catheter was advanced to the renal pelvis and the wire removed. Urine was collected and sent for culture. The wire was replaced and after removing the yellow catheter, a 6Fr x 26cm stent was passed under direct vision. The wire was then removed with formation of a distal curl in the bladder seen under direct vision. A proximal curl was noted in the upper pole of the kidney on fluoroscopy. The bladder was subsequently drained and the cystoscope removed to end the procedure.
CPT description: The physician passes the cystourethroscope through the urethra into the bladder and inserts an instrument through the cystourethroscope to extract, fragment, or manipulate a calculus in the ureter.... Report 52330 if the physician uses an instrument to manipulate, not remove, the calculus.
Indications:
This is a 63 y.o. male with a 4-5mm RT proximal ureteral stone in the setting of low grade fever.
The patient was brought to the operative suite and placed in the supine position and general anesthesia administered before repositioning in dorsolithotomy with adequate padding. The genitals were prepped and draped in normal sterile fashion. A 22 French rigid cystoscope was subsequently passed per urethra into the bladder. The urethra appeared normal with mild lateral lobe coaptation of the prostate and no bladder neck elevation. Once in the bladder, the urothelium was inspected with no lesions seen.
The RT ureteral orifice was identified and cannulated with a guidewire. A 5 French catheter was passed into the intramural tunnel. The guidewire was then passed through the yellow catheter to the level of the kidney after manipulating the stone so that the wire could pass beyond it. Pollick catheter was advanced to the renal pelvis and the wire removed. Urine was collected and sent for culture. The wire was replaced and after removing the yellow catheter, a 6Fr x 26cm stent was passed under direct vision. The wire was then removed with formation of a distal curl in the bladder seen under direct vision. A proximal curl was noted in the upper pole of the kidney on fluoroscopy. The bladder was subsequently drained and the cystoscope removed to end the procedure.
CPT description: The physician passes the cystourethroscope through the urethra into the bladder and inserts an instrument through the cystourethroscope to extract, fragment, or manipulate a calculus in the ureter.... Report 52330 if the physician uses an instrument to manipulate, not remove, the calculus.