Procedure details and findings:
Patient was explained the procedure and its risk factors in detail. Written and oral consent was obtained. Patient was placed prone on the fluoroscopy table and region of interest was prepped and draped in usual sterile fashion.
After giving 5 cc of buffered lidocaine a 20-gauge needle was advanced in the collecting system through the upper pole calyx with fluoroscopy guidance. Contrast was injected and collecting system was opacified.
018 guidewire was passed through the needle. A neffset dilator/sheath was advanced over the guidewire into the upper ureter. The inner dilator and guidewire was removed. 035 guidewire was passed through the sheath and advanced in the urinary bladder. The sheath was removed and it was replaced by 5 French angled glide catheter over the guidewire. The catheter tip is placed in the urinary bladder.
Similarly another access was provided to the middle pole calyx as discussed with referring physician.
Catheters were secured by 2-0 silk and sterile dressing was applied.
The procedure was done without any immediate complications. Patient left the procedure when a stable condition.
IMPRESSION:
Successful placement of the percutaneous nephrostomy access to the upper and middle pole calyx.
would i could 50393/74480 once or code it x2 since the dr. put one in the upper and middle
Patient was explained the procedure and its risk factors in detail. Written and oral consent was obtained. Patient was placed prone on the fluoroscopy table and region of interest was prepped and draped in usual sterile fashion.
After giving 5 cc of buffered lidocaine a 20-gauge needle was advanced in the collecting system through the upper pole calyx with fluoroscopy guidance. Contrast was injected and collecting system was opacified.
018 guidewire was passed through the needle. A neffset dilator/sheath was advanced over the guidewire into the upper ureter. The inner dilator and guidewire was removed. 035 guidewire was passed through the sheath and advanced in the urinary bladder. The sheath was removed and it was replaced by 5 French angled glide catheter over the guidewire. The catheter tip is placed in the urinary bladder.
Similarly another access was provided to the middle pole calyx as discussed with referring physician.
Catheters were secured by 2-0 silk and sterile dressing was applied.
The procedure was done without any immediate complications. Patient left the procedure when a stable condition.
IMPRESSION:
Successful placement of the percutaneous nephrostomy access to the upper and middle pole calyx.
would i could 50393/74480 once or code it x2 since the dr. put one in the upper and middle