Wiki Coding help

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Hi All,
I need help with the following coding scenario any help is appreciated
Operative Report
Preoperative Diagnosis: Left ureteral and kidney stone
Postoperative Diagnosis: Left ureteral and kidney stone
Indications:
This is a 52-year old male with a stone in his left ureter and left kidney. The stones have been there for
several months causing recurrent episodes of renal colic.
Findings:
The patient has a stone in his left mid-ureter, about 1 cm in size. Above the stone there is
hydronephrosis. The urethral and prostate appear normal. The bladder mucosa is normal.
Procedure:
The patient was anesthetized and placed in the lithotomy position. He was prepped and draped in the
normal manner. We started the procedure with a cystoscopy. We examined the urethra and the bladder.
We identified the left ureteral orifice. We used a cone-tip ureter catheter to inject contrast retrogradely
and to outline the ureter and stone. We then used an open-ended catheter to advance a guide wire
through the left ureter. The regular guide wire would not go above the stone, so we managed to get a
glide wire above the stone. We then advanced the ureteral catheter and exchanged the glide wire with a
stiff wire.
We removed the ureter catheter. We removed the cystoscope. We introduced a #12 French sheath and
then got another wire through the sheath above the stone and then removed the sheath. We introduced
it over the second wire and removed the wires, so we had safety wire outside the sheath and the sheath
leading to the stone. We used a #8 French flexible ureteroscope up the ureter until we identified the
stone. We used a #2.5 French laser fiber pulse to break the stone. We then used the basket to remove
some fragments. We then removed the sheath and used a #8 French rigid ureterscope to go up the
ureter to the stone. We used the laser fiber one more time and then removed all the fragments with 0-tip
basket. We then went up over the ureter up to the kidney and inspected, found no more fragments and
then left the patient with 4.7 x24.0 cm stent in his left ureter. The position was verified by fluoroscopy and
cystoscopy. The patient was verified by fluoroscopy and cystoscopy. The patient tolerated the
procedure well and was transferred to the recovery room in stable condition. No Foley catheter left in
place.
 
first look up hydronephresis there are combo diagnosis codes for that. Stones = Calculus in the index.

Look through the Cystourethroscopy codes (52000-52442) and you should be able to find the code you are looking for.

Look for pyelogram retrograde in the index and it will direct you to urography

do not for get about the hcpcs code for the stent...it will start with a C
 
I would use 52356 for the Cystourethroscopy w/ lithotripsy and stent placement.

N20.2 Calculus of kidney with calculus of ureter

Machelle Freeman, CPC
 
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