Hoping someone can help me to confirm my coding for the following op report. I am new to Urology coding and would just like to get some feedback as to whether or not I am coding correctly.
I am coding the following report with CPT Codes - 52353, 52352-59, 52332, & possibly 52341 for the dilation. Not sure if I am able to capture the dilation code, does not show bundled according to CCI edits.
Thanks in advance for your help : )
PREOPERATIVE DIAGNOSIS: Left distal nephrolithiasis.
POSTOPERATIVE DIAGNOSIS: Left distal nephrolithiasis.
OPERATION PERFORMED: Cystourethroscopy, left ureteroscopy, laser
lithotripsy, left retrograde pyelogram, and left stent placement.
BLOOD LOSS: Minimal.
DRAINS: A 6 x 24 double-J stent.
COMPLICATIONS: None.
INDICATION FOR PROCEDURE: Jane Doe is a 42-year-old female with a history of severe left flank pain and left flank hydronephrosis and with
impacted 5 to 6 mm left distal stone. She failed conservative therapy and
decided to proceed with surgical intervention.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient.
She was then taken back to the operative suite. Anesthesia was induced
without incident. She was given perioperative antibiotics. She was placed
in dorsal lithotomy position, prepped and draped in the usual sterile
fashion. At this point in time, a cystoscope was inserted into the
patients bladder. The urethra was normal without any evidence of masses,
strictures, or lesions. Circumferential examination of the bladder showed
no mucosal abnormalities. Both ureteral orifices were orthotopic and the
right orifice was effluxing clear urine. The left ureteral orifice was
identified and a gentle retrograde pyelogram was shot showing moderate
hydroureteronephrosis. A sensor tip guidewire was advanced up into the left
renal pelvis. At this point in time, the cystoscope was exchanged for the
ureteroscope and the ureteroscope was advanced into the distal ureter. There
was a fair amount of edema in the ureter required dilatation with the
ureteral access sheath. Once we had adequately dilated the distal ureter,
the ureteroscope was reinserted and the stone was visualized. It was
approximately 5 to 6 mm in size. Using the 265 micron holmium laser fiber,
the stone was ablated into small fragments. These were extracted with the
Nitinol stone basket and sent to pathology for chemical analysis. A
completion ureteroscopy showed no evidence of residual calculi.
Postprocedure retrograde pyelogram shows no extravasation of urine. The
ureteroscope was removed. A 6 x 24 double-J ureteral stent was advanced up
into the renal pelvis under fluoroscopic and direct vision. There was good
curl in the renal pelvis and the bladder. The bladder was then drained and
the patient returned to the post anesthesia care unit in stable condition.
Thanks again,
I am coding the following report with CPT Codes - 52353, 52352-59, 52332, & possibly 52341 for the dilation. Not sure if I am able to capture the dilation code, does not show bundled according to CCI edits.
Thanks in advance for your help : )
PREOPERATIVE DIAGNOSIS: Left distal nephrolithiasis.
POSTOPERATIVE DIAGNOSIS: Left distal nephrolithiasis.
OPERATION PERFORMED: Cystourethroscopy, left ureteroscopy, laser
lithotripsy, left retrograde pyelogram, and left stent placement.
BLOOD LOSS: Minimal.
DRAINS: A 6 x 24 double-J stent.
COMPLICATIONS: None.
INDICATION FOR PROCEDURE: Jane Doe is a 42-year-old female with a history of severe left flank pain and left flank hydronephrosis and with
impacted 5 to 6 mm left distal stone. She failed conservative therapy and
decided to proceed with surgical intervention.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient.
She was then taken back to the operative suite. Anesthesia was induced
without incident. She was given perioperative antibiotics. She was placed
in dorsal lithotomy position, prepped and draped in the usual sterile
fashion. At this point in time, a cystoscope was inserted into the
patients bladder. The urethra was normal without any evidence of masses,
strictures, or lesions. Circumferential examination of the bladder showed
no mucosal abnormalities. Both ureteral orifices were orthotopic and the
right orifice was effluxing clear urine. The left ureteral orifice was
identified and a gentle retrograde pyelogram was shot showing moderate
hydroureteronephrosis. A sensor tip guidewire was advanced up into the left
renal pelvis. At this point in time, the cystoscope was exchanged for the
ureteroscope and the ureteroscope was advanced into the distal ureter. There
was a fair amount of edema in the ureter required dilatation with the
ureteral access sheath. Once we had adequately dilated the distal ureter,
the ureteroscope was reinserted and the stone was visualized. It was
approximately 5 to 6 mm in size. Using the 265 micron holmium laser fiber,
the stone was ablated into small fragments. These were extracted with the
Nitinol stone basket and sent to pathology for chemical analysis. A
completion ureteroscopy showed no evidence of residual calculi.
Postprocedure retrograde pyelogram shows no extravasation of urine. The
ureteroscope was removed. A 6 x 24 double-J ureteral stent was advanced up
into the renal pelvis under fluoroscopic and direct vision. There was good
curl in the renal pelvis and the bladder. The bladder was then drained and
the patient returned to the post anesthesia care unit in stable condition.
Thanks again,