Hey ya'll!
I need help deciphering how to code this.
The scheduling form had it already preselected for 52353: Ureteroscopy using laser. However no where is the note is there mention of a laser being used on a stone.
I was potentially thinking 52310, or 52352. for the "Ureteroscopy with stone basket extraction"
I know the cysto and JJ stent is 52332
Please help! Thank you!
Procedure: Procedure(s):
Right ureteroscopy with stone basket extraction
Cystoscopy and right ureteral stent placement
The patient was brought to the operative suite on 2/17/2025. Side and site were marked and verified. A timeout was performed by all members of the surgical team prior to the induction of anesthesia. Following the induction of general anesthesia, the patient was placed in the modified dorsolithotomy position and the perineum and genitalia were prepped and draped in sterile fashion. A 21 French cystoscope sheath was passed per urethra into the bladder. Panendoscopy of bladder was performed after the bladder was drained. There was no evidence of tumor or stone or diverticulum in the bladder. Both ureteral orifices were located in the normal anatomic positions. There was mild diffuse trabeculation of the bladder walls. 30 degree lens was used to localize the right ureteral orifice and a floppy tip Glidewire was passed into the right distal ureter and proximally under combined fluoroscopic and cystoscopic guidance to curl in an area overlying the right renal shadow. The scope was backed out over the wire. A double-lumen ureteral cath was passed over the wire and into the right distal ureter under low pressure and with minimal resistance. The catheter was then backed out over the wire and the wire was secured to the drape for access. A rigid ureteroscope was driven into the bladder under direct vision into the right distal ureter and proximally from the right UVJ to the right UPJ. There was a single stone that was approximately 8 mm long by 5 mm wide. There were no other stone fragments noted along the course of the right ureter. There were no intraluminal ureteral abnormalities noted on the right. The scope was parked just outside of the ureteral stone. A 0 tip nitinol basket was used to grasp the stone and a lengthwise. The stone was carefully brought out under direct vision and sent for stone composition analysis. This is a 7 French by 22 cm JJ ureteral stent with the string attached was passed over the indwelling right ureteral Glidewire and into the right ureter and proximally under fluoroscopic guidance. The wire was removed. There was a proximal ureteral stent curl overlying the right renal shadow seen fluoroscopically. Cystoscopy showed a good distal ureteral stent curl emanating the right ureteral orifice. The bladder was drained and the scope was removed. The stent string was secured to the right suprapubic skin off tension using tape.
The patient was reversed from anesthesia and taken to the PACU in stable condition for recovery. She tolerated the procedure well.
I need help deciphering how to code this.
The scheduling form had it already preselected for 52353: Ureteroscopy using laser. However no where is the note is there mention of a laser being used on a stone.
I was potentially thinking 52310, or 52352. for the "Ureteroscopy with stone basket extraction"
I know the cysto and JJ stent is 52332
Please help! Thank you!
Procedure: Procedure(s):
Right ureteroscopy with stone basket extraction
Cystoscopy and right ureteral stent placement
The patient was brought to the operative suite on 2/17/2025. Side and site were marked and verified. A timeout was performed by all members of the surgical team prior to the induction of anesthesia. Following the induction of general anesthesia, the patient was placed in the modified dorsolithotomy position and the perineum and genitalia were prepped and draped in sterile fashion. A 21 French cystoscope sheath was passed per urethra into the bladder. Panendoscopy of bladder was performed after the bladder was drained. There was no evidence of tumor or stone or diverticulum in the bladder. Both ureteral orifices were located in the normal anatomic positions. There was mild diffuse trabeculation of the bladder walls. 30 degree lens was used to localize the right ureteral orifice and a floppy tip Glidewire was passed into the right distal ureter and proximally under combined fluoroscopic and cystoscopic guidance to curl in an area overlying the right renal shadow. The scope was backed out over the wire. A double-lumen ureteral cath was passed over the wire and into the right distal ureter under low pressure and with minimal resistance. The catheter was then backed out over the wire and the wire was secured to the drape for access. A rigid ureteroscope was driven into the bladder under direct vision into the right distal ureter and proximally from the right UVJ to the right UPJ. There was a single stone that was approximately 8 mm long by 5 mm wide. There were no other stone fragments noted along the course of the right ureter. There were no intraluminal ureteral abnormalities noted on the right. The scope was parked just outside of the ureteral stone. A 0 tip nitinol basket was used to grasp the stone and a lengthwise. The stone was carefully brought out under direct vision and sent for stone composition analysis. This is a 7 French by 22 cm JJ ureteral stent with the string attached was passed over the indwelling right ureteral Glidewire and into the right ureter and proximally under fluoroscopic guidance. The wire was removed. There was a proximal ureteral stent curl overlying the right renal shadow seen fluoroscopically. Cystoscopy showed a good distal ureteral stent curl emanating the right ureteral orifice. The bladder was drained and the scope was removed. The stent string was secured to the right suprapubic skin off tension using tape.
The patient was reversed from anesthesia and taken to the PACU in stable condition for recovery. She tolerated the procedure well.