drobinson1
Networker
Good afternoon coders. I need help coding the following report. I'm thinking
75984/51705 but I want to be sure. The other coder I work with said 75989/51102. Thanks.
Reason For Study: replace suprapubic tube-pt quadraplegic
History: A 30-year-old male who is quadriplegic and has had suprapubic catheter for a approximately 10 years. 10 days ago, the nurse pulled the catheter out and was unable to replace it. A Foley catheter has been placed in the interim.
The bladder was slowly distended with 500 cc of saline.
The site of a prior suprapubic access was cleansed with Betadine solution. Under fluoroscopic guidance, a 5 French dilator and Glidewire were used to negotiate the pathway into the urinary bladder was which was successful.
The dilator was exchanged for a 5 French cobra catheter. The guidewire was then exchanged for an Amplatz superstiff guidewire. Successive dilators were advanced across the suprapubic tract. After dilating with a 20 French dilator, a 20 French Foley catheter was unable to be advanced over guidewire into the bladder. Therefore, an 18 French Foley catheter was successfully advanced across the tracts into the urinary bladder. This was confirmed with contrast injection into the urinary bladder through transurethral Foley catheter. Subsequently, the transurethral Foley catheter was removed. The 18 French suprapubic Foley catheter was retained with injection of 5 cc saline into the retention balloon. The suprapubic catheter was connected to a external drainage bag.
Impression:
1. Original suprapubic tract was catheterized successfully.
2. An 18 French Foley catheter was placed into the urinary bladder via the suprapubic tract.
75984/51705 but I want to be sure. The other coder I work with said 75989/51102. Thanks.
Reason For Study: replace suprapubic tube-pt quadraplegic
History: A 30-year-old male who is quadriplegic and has had suprapubic catheter for a approximately 10 years. 10 days ago, the nurse pulled the catheter out and was unable to replace it. A Foley catheter has been placed in the interim.
The bladder was slowly distended with 500 cc of saline.
The site of a prior suprapubic access was cleansed with Betadine solution. Under fluoroscopic guidance, a 5 French dilator and Glidewire were used to negotiate the pathway into the urinary bladder was which was successful.
The dilator was exchanged for a 5 French cobra catheter. The guidewire was then exchanged for an Amplatz superstiff guidewire. Successive dilators were advanced across the suprapubic tract. After dilating with a 20 French dilator, a 20 French Foley catheter was unable to be advanced over guidewire into the bladder. Therefore, an 18 French Foley catheter was successfully advanced across the tracts into the urinary bladder. This was confirmed with contrast injection into the urinary bladder through transurethral Foley catheter. Subsequently, the transurethral Foley catheter was removed. The 18 French suprapubic Foley catheter was retained with injection of 5 cc saline into the retention balloon. The suprapubic catheter was connected to a external drainage bag.
Impression:
1. Original suprapubic tract was catheterized successfully.
2. An 18 French Foley catheter was placed into the urinary bladder via the suprapubic tract.