toria11
Guru
Hi! Please see the note below, I'm not sure how to code this. The physician is calling it a consult but he did dissect into the pelvis to check on the ureter. Thoughts? Thank you as always!!
Consultation
REASON FOR CONSULTATION:
Help identifying the left ureter.
INDICATIONS FOR PROCEDURE:
The patient is a __________-year-old gentleman with history of sigmoid diverticulitis, status post CT-guided percutaneous catheter placement. Dr. L**** was doing exploratory laparotomy with excision of the colon and wanted assistance in identifying and preserving the left ureter. I reviewed the films, and CT scan showed no hydronephrosis but there was a large aortic aneurysm extending into the iliacs.
PROCEDURE:
I scrubbed into the case, and Dr. L**** had already exposed the left retroperitoneum and had partially identified the left ureter. I dissected all the way down into the pelvis, and it was intact and injured and well away from the area of dissection in the pelvis. I did not feel the need to perform cystoscopy or pass a stent. I then scrubbed out and turned the case back over to Dr. L****.
Consultation
REASON FOR CONSULTATION:
Help identifying the left ureter.
INDICATIONS FOR PROCEDURE:
The patient is a __________-year-old gentleman with history of sigmoid diverticulitis, status post CT-guided percutaneous catheter placement. Dr. L**** was doing exploratory laparotomy with excision of the colon and wanted assistance in identifying and preserving the left ureter. I reviewed the films, and CT scan showed no hydronephrosis but there was a large aortic aneurysm extending into the iliacs.
PROCEDURE:
I scrubbed into the case, and Dr. L**** had already exposed the left retroperitoneum and had partially identified the left ureter. I dissected all the way down into the pelvis, and it was intact and injured and well away from the area of dissection in the pelvis. I did not feel the need to perform cystoscopy or pass a stent. I then scrubbed out and turned the case back over to Dr. L****.