PCNL with additional work (more than 50081?)


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Looking for some advice on the following (the relevant details are in bold):


OPERATION: Left percutaneous nephrolithotomy.

The patient has upper pole kidney stones,
one of them more medially, approximately 14 mm to 15 mm
greatest length on CAT scan, another one smaller 8 to 9 mm at
another part of the upper pole. On his arrival to the preop area,
the patient was sent to Interventional Radiology and the Dr.____
placed a nephroureteral access catheter with two wires going into
the bladder. In his opinion, the patient has the large stone burden
within a diverticulum with acute angle towards the pelvis which was
demonstrated on nephrostogram although he was able to easily pass
the wires.

The patient was identified in the waiting room and brought into the
OR on the stretcher. General anesthesia was administered. A Foley
catheter was placed. The patient was then flipped onto the OR table
into the prone position. Two rolls were placed under him. Axillary
rolls and shoulder pads were secured as well. All pressure points
including elbows and feet were secured. The patient's left flank
was then prepped and draped in the sterile surgical fashion.
Time-out was performed. Consent and laterality were verified. The
patient received 2 g of Ancef before Interventional Radiology and
another 160 g of gentamicin before the PCNL.

Fluoroscopy was brought in. Both stones were identified on fluoro.
Due to the very medial location of the nephroureteral stent and the
medial stone, the nephroureteral access catheter was going in at a
complete vertical direction very medial close to the spine. The
C-arm thought to be rotated 45 degrees. At this point, I prepped
the nephroureteral access catheter with some additional Betadine and
removed the two wires that he had placed, a new Amplatz Super Stiff
wire and a regular Sensor wire. I then slowly removed the
nephroureteral access catheter to the level of the renal pelvis and
injected some contrast to opacify the collecting system confirming
the larger stone burden location more medially where the ureteral
access sheath was going through. Another stone still in the upper
pole but at a much lateral position on the kidney was identified
with an acute angle between the two stones. Next, the
nephroureteral access catheter was removed. The point of wire entry
into the skin was extended with a #11 blade approximately 12 mm.
Next, a NephroMax made by Bard balloon was inserted over the Amplatz
wire. The 30-French sheath was placed over the wire as well. I
then advanced the balloon tip to the level of the upper pole calyx
where the stone was and inflated the balloon to 18 cm of water. I
then attached the 30-French sheath over the balloon into the calyx
and removed the deflated balloon and removed it. Next, I introduced
a 26-French nephroscope using continuous irrigation was inserted
through the tract into the upper pole.
Careful inspection revealed
that the patient had multiple conglomerate of stones rather than one
large stone measuring in size from 3 to about 6 to 7 mm. Due to the
acute angle of the infundibulum, I had a hard time rotating the
nephroscope to access all the stones, but I was able to insert the
ultrasonic Lithotripter, and using ultrasound and some LithoClast
activity I removed some of the stone burden.
The patient still had
multiple stones deeper in the calyx and therefore removed the rigid
nephroscope and inserted a flexible cystoscope into the calyx, and
using a Nitinol basket I was able to retrieve the remaining stones.

At least six or seven of them were manually removed and sent for
Reinspection revealed no residual stones in the medial
calyx. I could not access the other upper pole calyx with the
remaining stone due to the acute angle between the two calices. The
renal pelvis was inspected. It was intact. I did not see any
stones in the renal pelvis or UPJ. Next, the collecting system was
opacified, and over the Amplatz wire I passed a 6 x 28 stent through
the nephroscope and noted coiled in the bladder and in the renal
Next, the nephrostomy sheath was removed and after _____ I
passed a 22-French Council tip Foley catheter over the Sensor wire.
The tip of the catheter was noted to be in the upper pole calyx
although I did migrate somewhat distally after the balloon was
inflated with 1.5 mL of sterile water, but I was able to easily
irrigate the system.
Some extravasation was noted, mostly from the
tract coming out adjacent to the 20-French Council tip. No
significant bleeding was noted. The Council tip nephrostomy tube
was secured to the skin with a 3-0 nylon stitch.
A 4 x 4 dressing
and Tegaderm were then used to secure it in place. I then flipped
the patient into the supine position. The patient tolerated the
procedure well, was extubated, and sent to the recovery room in
stable condition.

Initially, I was going to bill just 50081 for the PCNL and 50684 for contrast. However, the level of detail & reading I've done suggests I can add on 52352 for the work involving the cystoscopic (vs the nephroscope) basket removal of calculi and 50395 (or 50432?) as I think the #11 blade incision extension counts as a new access? Perhaps I'm overanalyzing this one. Any help would be appreciated. Thanks.