Please see below. For anesthesia charges, would you code 00918 or 01922?
OPERATION PERFORMED:
Cystoureteroscopy, right stone basket extraction, retrograde pyelogram, stent
insertion.
DRAIN:
A 7-French variable length stent.
DESCRIPTION OF PROCEDURE:
Patient was taken down to suite, after time out and briefing were done patient was
then intubated and placed in dorsal lithotomy position. Patient's perineum was
prepped and draped in the usual sterile fashion. There vaginal exam is negative
for any masses, no cystocele. Good apical support. Urethra is entered, no
masses are seen. Bladder was surveyed. There are no foreign bodies or masses
seen. Ureter was entered, found normal position, normal caliber. Right UO was
identified and a wire was placed into this. A rigid scope was placed into this
and taken to the level distally. The stone was identified, grasped with a Cook
and circle basket and removed in 1 piece. I replaced the scope and take this up
into the collecting system. Patient has a large renal pelvis. I then removed this
partially and did a retrograde pyelogram showing again a very large dilated
renal pelvis with hydroureter. Leaving the wire in place I placed a 7-French
variable length stent with good curl in the renal pelvis and distally into the
bladder to help to increase the drainage from that right side to decrease any
possibility for any urinoma formation. Patient's bladder was drained.
OPERATION PERFORMED:
Cystoureteroscopy, right stone basket extraction, retrograde pyelogram, stent
insertion.
DRAIN:
A 7-French variable length stent.
DESCRIPTION OF PROCEDURE:
Patient was taken down to suite, after time out and briefing were done patient was
then intubated and placed in dorsal lithotomy position. Patient's perineum was
prepped and draped in the usual sterile fashion. There vaginal exam is negative
for any masses, no cystocele. Good apical support. Urethra is entered, no
masses are seen. Bladder was surveyed. There are no foreign bodies or masses
seen. Ureter was entered, found normal position, normal caliber. Right UO was
identified and a wire was placed into this. A rigid scope was placed into this
and taken to the level distally. The stone was identified, grasped with a Cook
and circle basket and removed in 1 piece. I replaced the scope and take this up
into the collecting system. Patient has a large renal pelvis. I then removed this
partially and did a retrograde pyelogram showing again a very large dilated
renal pelvis with hydroureter. Leaving the wire in place I placed a 7-French
variable length stent with good curl in the renal pelvis and distally into the
bladder to help to increase the drainage from that right side to decrease any
possibility for any urinoma formation. Patient's bladder was drained.
