PCNL with New Access?

toria11

Networker
Messages
75
Location
Clearwater, FL
Best answers
0
Hi! I'd like a second opinion on how I've coded this procedure. Thanks!

50081-LT
50432-52-LT
52332-50
52005
74420-26

Indication for operation: Bilateral staghorn calculus. Plan for staged bilateral PCNL. We will first
treat the left staghorn calculus which measures 5.1 x 2.9 x 2.4 centimeter
Findings: Bilateral 26 centimeters x 6 French double-J ureteral stent placed. Percutaneous
access to the left lower pole renal calyx was obtained.
Drains: Bilateral 26 centimeters x 6 French double-J ureteral stents without danglers. Sixteen
French Foley catheter. Twenty French left nephrostomy tube
Operation performed:
1. Cystoscopy with bilateral ureteral stents placement. Percutaneous access to the collecting
system. Dilation of percutaneous tract to the collecting system. The flap placement of
percutaneous tract access to the collecting system. Left percutaneous nephrolithotomy > 2cm
Description of operation: After informed consent was obtained, the patient was brought back to
operating room and underwent general endotracheal anesthesia. He was placed in the low
lithotomy position. His genitalia was prepped and draped in a sterile surgical manner. A time-out
was performed.
A 22 French rigid cystoscope was inserted into the urethra advanced to the bladder. The right
ureteral orifice was identified. A guidewire was placed in right ureter advanced the right renal
pelvis under fluoroscopic guidance. A 26 centimeters x 6 French double-J ureteral stent was
placed into the right ureter. Correct position was confirmed under fluoroscopy. Attention was
turned towards the left ureteral orifice. A guidewire was placed in the left ureter and advanced to
left renal pelvis under fluoroscopic guidance. The occluding balloon catheter was then placed
over the guidewire and the tip of the occluding balloon catheter was placed at the UPJ. A
retrograde pyelogram was performed to confirm proper placement. The occluding balloon was
then inflated. The cystoscope was removed. A 16 French Foley catheter was placed. The
occluding balloon catheter was secured to the Foley catheter. Patient was returned to the supine
position and then placed in the prone position with all the pressure points padded. His left flank
was then prepped and draped in a sterile surgical manner.
A retrograde pyelogram was performed using the occluding balloon catheter with a mixture of
saline, contrast, and methylene blue. The lower pole calyx was then targeted. An 18 gauge
trocar needle was then advanced from the left flank and into the lower pole renal calyx. Entry into
the collecting system was confirmed with return of methylene blue fluid. A guidewire was placed
into the trocar needle and advanced into the upper pole. The trocar needle was then removed
and the skin was incised to approximately 1 centimeter. The tract was then sequentially dilated
from 6 French to 12 French. At 12 French a second guidewire was placed. One guidewire was
secured to the drapes with a second guidewire was used to advance the nephrostomy tube
balloon dilator. The balloon was inflated to 30 French and the nephrostomy sheath was placed
over the balloon dilator. This established the percutaneous access to the collecting system.
A nephroscope was then placed into the nephrostomy sheath and advanced into the lower pole
where multiple small stones were identified along with the large staghorn calculus. Using the
ultrasonic Lithotripter the staghorn calculus was fragmented and suctioned out. The smaller
stone was also fragmented and suctioned out. The left UPJ was then identified. However,
placing the guidewire into the left ureter was difficult due to the angulation. Subsequently a
flexible cystoscope was placed and a guidewire was placed into the left ureter and advanced into
the bladder. The occluding balloon catheter was then removed. A 26 centimeters x 6 French
double-J ureteral stent was placed into the left ureter. Correct position was confirmed under
fluoroscopy. The lower pole renal calices were inspected further along with the renal pelvis and
upper pole calyx. Any smaller stone fragments that were identified with then fragmented and
suctioned out. The nephroscope was removed and a 20 French Council tip catheter was placed
over the guidewire and into the renal pelvis. The nephrostomy sheath was then removed. Proper
placement of the nephrostomy tube was confirmed with an antegrade nephrostogram. The
nephrostomy tube was then secured using 2 0 nylon. All guidewires were removed. Sterile
dressing was applied. Patient was returned to the supine position, extubated, and taken to the
recovery in stable condition.
Plan: Will admit overnight for observation and check labs in the morning.
 
Messages
234
Best answers
0
I would suggest the following coding fopr your clinical scenario:
50081-LT
50432-LT for renal access and for nephrostomy tube placement
52332-RT for the contralatweral JJ stent placement
52005-LT
The placement of the left stent via an antegrade approach is included in 50081 as well as the nephrostomy tract dilation. There is not enough dictation to bill 74420-26
 
Top