daniel
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A physician performs a retrograde ureteroscopically, lasering off the Randall plaques from multiple other calyces in addition to a PCNL. How is this reported? CPT 52353 hits for a CCI edit, but modifier 59 is allowed. Does documentation support reporting both codes? 50080-81, 52353?
OPERATIONS PERFORMED: Cystoscopy; right fluoro-less ureteroscopy; intraoperative ultrasound; intraoperative ultrasound interpretation of images; right laser DARRT percutaneous access into upper pole; right percutaneous tract dilatation; right percutaneous nephrostolithotomy of stone greater than 3 cm; right flexible nephroscopy and basket extraction of stones; right retrograde ureteroscopy with holmium laser lithotripsy of upper pole and ureteral stones; placement of right 8-French ConvertX nephroureteral stent; right antegrade nephrostogram; fluoroscopy interpretation.
INDICATION FOR OPERATION: This patient had large burden of stones filling the lower pole and lower pole infundibulum. There were 4 calyces full of stone. We discussed with him the options of percutaneous nephrostolithotomy versus shockwave lithotripsy versus ureteroscopy. He desired percutaneous nephrostolithotomy. The risks of this procedure were discussed in detail, including bleeding, infection, heart attack, stroke, death, reoperation, damage to local structures including nerves, arteries, blood vessels, and need for additional procedures. All questions were answered in detail, no promises or guarantees were in any way given or implied, and patient desired to proceed with the operation as explained.
PROCEDURE IN DETAIL: Following informed consent and review of preoperative labs, patient was taken to the operating room and placed under general anesthesia in the supine position. He was then placed prone and sterilely prepped and draped in the usual fashion. A flexible cystoscope was inserted into the bladder and the right ureter was identified. Using an angle-tip Glidewire, we advanced this up into the kidney. Using an end-hole catheter, we converted this to a double floppy Super Stiff guidewire. Over the double floppy Super Stiff guidewire, we placed a dual-lumen catheter and then a Glidewire and then a standard wire, so we had 2 wires in the kidney. Over the Super Stiff, we passed the flexible ureteroscope. This passed easily into the kidney. We mapped out and found the upper pole calyx. The lower pole, there was a lot of stone in the lower pole, but it was felt that the upper pole opposite would be a better access, so we went through the upper pole, and using intraoperative ultrasound, we mapped out that there was no lung in the way. Once I had mapped this out, then under fluoro using laser DARRT technique, we directed a needle into the upper pole calyx, grasped the wire ureteroscopically and pulled it down into the ureter. We then used a Glide catheter to get a Glidewire into the bladder and then placed a single floppy Super Stiff guidewire. We used the dual-lumen catheter to place another Glidewire and then converted this to a standard wire. With both wires in place, we placed the balloon into the kidney under direct vision and we performed tract dilation under direct vision ureteroscopically, and once we had inserted the scope, we realized that the upper pole infundibulum was fairly narrow. I could not get the scope through that or into the lower pole due the angles, so we had to go with the flexible scope. I made 100 passes into the lower pole using the NCompass basket and pulling out chunks. We used the NCircle basket to pull out some larger stone pieces and used the ultrasonic Lithotripter to vacuum up a lot of debris out of the renal pelvis and did ultrasonic lithotripsy. The total stone burden was 3.5 cm and it was filling the lower pole and lower pole infundibulum. Once we had cleared all this out, we did renal mapping. There were multiple Randall plaques that we cleared off using the basket and some lasering from above in an antegrade fashion, but the majority was done in a retrograde fashion ureteroscopically, lasering off the Randall plaques from multiple other calyces. Once we had cleared off all these Randall plaques, we then we came down and cleared the ureter, and there was no stone seen in the ureter. The ureter measured out at 24 cm. We then got a ConvertX 24 cm nephroureteral tube, which we positioned under direct vision, had a good curl in the bladder and a good curl in the renal pelvis. Once we had done this, we then shot a little bit of contrast and did antegrade nephrostogram, which showed that the tube was curled in the renal pelvis in perfect position. We cut the sheath to allow us to pull the sheath back and sew the stent into the skin, and a dry sterile dressing was applied. A Foley catheter was left in the bladder during the whole case. Finally, the patient was then placed supine, awakened, extubated, and transported to the recovery room in stable.
OPERATIONS PERFORMED: Cystoscopy; right fluoro-less ureteroscopy; intraoperative ultrasound; intraoperative ultrasound interpretation of images; right laser DARRT percutaneous access into upper pole; right percutaneous tract dilatation; right percutaneous nephrostolithotomy of stone greater than 3 cm; right flexible nephroscopy and basket extraction of stones; right retrograde ureteroscopy with holmium laser lithotripsy of upper pole and ureteral stones; placement of right 8-French ConvertX nephroureteral stent; right antegrade nephrostogram; fluoroscopy interpretation.
INDICATION FOR OPERATION: This patient had large burden of stones filling the lower pole and lower pole infundibulum. There were 4 calyces full of stone. We discussed with him the options of percutaneous nephrostolithotomy versus shockwave lithotripsy versus ureteroscopy. He desired percutaneous nephrostolithotomy. The risks of this procedure were discussed in detail, including bleeding, infection, heart attack, stroke, death, reoperation, damage to local structures including nerves, arteries, blood vessels, and need for additional procedures. All questions were answered in detail, no promises or guarantees were in any way given or implied, and patient desired to proceed with the operation as explained.
PROCEDURE IN DETAIL: Following informed consent and review of preoperative labs, patient was taken to the operating room and placed under general anesthesia in the supine position. He was then placed prone and sterilely prepped and draped in the usual fashion. A flexible cystoscope was inserted into the bladder and the right ureter was identified. Using an angle-tip Glidewire, we advanced this up into the kidney. Using an end-hole catheter, we converted this to a double floppy Super Stiff guidewire. Over the double floppy Super Stiff guidewire, we placed a dual-lumen catheter and then a Glidewire and then a standard wire, so we had 2 wires in the kidney. Over the Super Stiff, we passed the flexible ureteroscope. This passed easily into the kidney. We mapped out and found the upper pole calyx. The lower pole, there was a lot of stone in the lower pole, but it was felt that the upper pole opposite would be a better access, so we went through the upper pole, and using intraoperative ultrasound, we mapped out that there was no lung in the way. Once I had mapped this out, then under fluoro using laser DARRT technique, we directed a needle into the upper pole calyx, grasped the wire ureteroscopically and pulled it down into the ureter. We then used a Glide catheter to get a Glidewire into the bladder and then placed a single floppy Super Stiff guidewire. We used the dual-lumen catheter to place another Glidewire and then converted this to a standard wire. With both wires in place, we placed the balloon into the kidney under direct vision and we performed tract dilation under direct vision ureteroscopically, and once we had inserted the scope, we realized that the upper pole infundibulum was fairly narrow. I could not get the scope through that or into the lower pole due the angles, so we had to go with the flexible scope. I made 100 passes into the lower pole using the NCompass basket and pulling out chunks. We used the NCircle basket to pull out some larger stone pieces and used the ultrasonic Lithotripter to vacuum up a lot of debris out of the renal pelvis and did ultrasonic lithotripsy. The total stone burden was 3.5 cm and it was filling the lower pole and lower pole infundibulum. Once we had cleared all this out, we did renal mapping. There were multiple Randall plaques that we cleared off using the basket and some lasering from above in an antegrade fashion, but the majority was done in a retrograde fashion ureteroscopically, lasering off the Randall plaques from multiple other calyces. Once we had cleared off all these Randall plaques, we then we came down and cleared the ureter, and there was no stone seen in the ureter. The ureter measured out at 24 cm. We then got a ConvertX 24 cm nephroureteral tube, which we positioned under direct vision, had a good curl in the bladder and a good curl in the renal pelvis. Once we had done this, we then shot a little bit of contrast and did antegrade nephrostogram, which showed that the tube was curled in the renal pelvis in perfect position. We cut the sheath to allow us to pull the sheath back and sew the stent into the skin, and a dry sterile dressing was applied. A Foley catheter was left in the bladder during the whole case. Finally, the patient was then placed supine, awakened, extubated, and transported to the recovery room in stable.