toria11
Guru
Hi, billing for physician here. Provider planned on performing cystoscopy and left ureteroscopy with laser lithotripsy but was unable to identify the left ureteral orifice. Would it be appropriate to bill this as 52356-52 since 52356 was attempted? Thanks!
PROCEDURES PERFORMED: 1. Cystoscopy.
2. Attempted cannulation of the left ureteral
orifice and left ureteral system, however
unsuccessful.
PERTINENT FINDINGS:
1. Normal bladder without multiple lesions, multiple scars throughout the bladder however no evidence of
tumor recurrences or evidence of malignancy throughout the bladder.
2. Unable to adequately identify the left ureteral orifice again access to the left collecting system. Small
dimple was identified, difficult to visualize, however unable to be cannulate as this was pinpoint and
likely scarred over.
INDICATIONS FOR PROCEDURE: Alan Wheeler is a 67-year-old male with a history of high
grade urethral carcinoma of the bladder who underwent multiple treatment resections and BCG therapy
who was found recently to have a left sided nephrolithotripsy and left sided hydronephrosis and presents
now for treatment cystoscopy and left ureteroscopy and laser lithotripsy.
PROCEDURE IN DETAIL: After proper informed consent was obtained, the patient was brought to
the operating room and laid supine on the operating room table. The patient was placed under general
anesthesia. The patient was placed in the lithotomy position and prepped and draped in a standard sterile
fashion. After proper time-out was completed, the rigid cystoscope was inserted through the urethra into
the bladder. The urethral mucosa was within normal limits without any abnormalities however, there were
some mild structuring noted at the very distal tip of the urethra. This was successfully dilated up to 28
French and the scope was able to be passed beyond at this point and into the bladder. Upon entering the
bladder, the right ureteral orifice was easily identified. The remainder of the bladder inspected with
multiple scars throughout the bladder however no obvious tumors or lesions throughout. At this point,
attention was then turned to identify the left ureteral orifices. Following the trigone and approximating the
location based on the right ureteral orifice, the left ureteral orifice was unable to be identified. Multiple
attempts were identified this were unsuccessful. There was a small dimple that was identified and
multiple attempts of cannulation using a guidewire were unsuccessful. At this point, closed observation
felt like there was likely scar tissue or urothelial film overlying a possible ureteral orifice, however, this
was rather pinpoint unable to gain access through the left collecting system. Therefore, the patient’s
bladder was emptied and the scope was removed. The patient tolerated the procedure well without
complications. He was awoken from anesthesia and taken to PACU in good and stable condition.
DISPOSITION: The patient is to be with plans for left sided antegrade setting with IR and retro
radiology with possible indwelling and a grade stent placement. At which point, we will then proceed with
ureteroscopy once the access site had been obtained.
PROCEDURES PERFORMED: 1. Cystoscopy.
2. Attempted cannulation of the left ureteral
orifice and left ureteral system, however
unsuccessful.
PERTINENT FINDINGS:
1. Normal bladder without multiple lesions, multiple scars throughout the bladder however no evidence of
tumor recurrences or evidence of malignancy throughout the bladder.
2. Unable to adequately identify the left ureteral orifice again access to the left collecting system. Small
dimple was identified, difficult to visualize, however unable to be cannulate as this was pinpoint and
likely scarred over.
INDICATIONS FOR PROCEDURE: Alan Wheeler is a 67-year-old male with a history of high
grade urethral carcinoma of the bladder who underwent multiple treatment resections and BCG therapy
who was found recently to have a left sided nephrolithotripsy and left sided hydronephrosis and presents
now for treatment cystoscopy and left ureteroscopy and laser lithotripsy.
PROCEDURE IN DETAIL: After proper informed consent was obtained, the patient was brought to
the operating room and laid supine on the operating room table. The patient was placed under general
anesthesia. The patient was placed in the lithotomy position and prepped and draped in a standard sterile
fashion. After proper time-out was completed, the rigid cystoscope was inserted through the urethra into
the bladder. The urethral mucosa was within normal limits without any abnormalities however, there were
some mild structuring noted at the very distal tip of the urethra. This was successfully dilated up to 28
French and the scope was able to be passed beyond at this point and into the bladder. Upon entering the
bladder, the right ureteral orifice was easily identified. The remainder of the bladder inspected with
multiple scars throughout the bladder however no obvious tumors or lesions throughout. At this point,
attention was then turned to identify the left ureteral orifices. Following the trigone and approximating the
location based on the right ureteral orifice, the left ureteral orifice was unable to be identified. Multiple
attempts were identified this were unsuccessful. There was a small dimple that was identified and
multiple attempts of cannulation using a guidewire were unsuccessful. At this point, closed observation
felt like there was likely scar tissue or urothelial film overlying a possible ureteral orifice, however, this
was rather pinpoint unable to gain access through the left collecting system. Therefore, the patient’s
bladder was emptied and the scope was removed. The patient tolerated the procedure well without
complications. He was awoken from anesthesia and taken to PACU in good and stable condition.
DISPOSITION: The patient is to be with plans for left sided antegrade setting with IR and retro
radiology with possible indwelling and a grade stent placement. At which point, we will then proceed with
ureteroscopy once the access site had been obtained.