toria11
Guru
Hi! Is 50785 the only code I can bill for this procedure? I read an article that said I could bill "50785 for the reimplantation via the Boari technique, 50650-51 (Ureterectomy, with bladder cuff [separate procedure]; Multiple procedures) for the excision of the segment of the ureter and 38770-51 (Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes [separate procedure]) for the unilateral node resection. If you stent your anastomosis with a JJ-stent, also code 50605-51" however, it seems all codes except 50785 are bundled/separate procedures. The patient also has a Medicare plan so I wouldn't use modifier 51. Thoughts? Thanks!
Preoperative diagnosis: Left ureteral cancer
Postoperative diagnosis: Same
Findings: Approximately 3 centimeter left mid ureteral mass consistent with the ureteral cancer.
Negative frozen section ureteral margin on the third specimen.
Specimens:
1. Left distal ureter
2. Left pelvic lymph node
3. Left distal ureteral margin 1.-frozen section
4. Left distal ureteral margin 2.-frozen section
5. Left distal ureteral margin 3.-frozen section
Drains:
1. 26 centimeters x 8 French double-J ureteral stent without danglers
2. 20 French Foley catheter
3. 15 French Blake drain
Operation performed:
1. Left distal ureterectomy with ureteral reimplant
2. Boari flap
3. Left ureteroscopy
4. Left pelvic lymph node dissection
Description of operation: After informed consent was obtained, the patient was brought back to
operating room and underwent general endotracheal anesthesia. Bilateral TAP blocks were
performed. His abdomen and genitalia were prepped and draped in a sterile surgical manner. A
time-out was performed.
A 20 French Foley catheter was placed. A midline incision was made from the epigastrium to the
pubic symphysis. Dissection carried down to the subcutaneous tissue and the linea alba was
divided. The space of Retzius was entered along with the peritoneum. A Bookwalter retractor
was used to provide exposure. The white line of Toldt was then incised and the descending
colon was reflected anterior medially. The proximal left ureter was identified. The left proximal
ureter was isolated and dissection was carried distally. The ureteral mass was palpable at the
mid ureter. The ureter was then and dissected down to the UVJ. UVJ and bladder was clamped
off using a tonsil. The ureter proximal and distal to the ureteral mass was clipped. The ureter
proximal to the renal mass was then divided. Dissection was then excised and passed off as
specimen for the frozen section. The first ureteral margin was suspicious for malignancy. A
second frozen margin was then given. This came back positive for malignancy. The third margin
returned negative for malignancy. By this point the end of the ureteral margin was approximately
2 centimeters proximal to the common left iliac artery. While waiting for the frozen section to
return, a left pelvic lymph node dissection was performed with the margins of the iliac vessels, the
obturator nerve, the femoral canal, and the iliac bifurcation. The left distal ureter was removed
and passed off as specimen. The bladder margin was closed using 2 0 Vicryl in a running
fashion. A flexible ureteroscope was then placed into the remaining left ureter and advanced to
the renal pelvis. Examination of the ureteral and renal pelvis mucosa showed no abnormalities.
Due to the distance of the distal ureteral margin to the bladder, a Boari flap was required. The
Boari flap was created using the dome of the bladder. The left distal ureter was speculated. The
ureter was anastomosed to the bar flap using 3 0 and 4 0 Vicryl in a interrupted and running
fashion. A guidewire was placed into the left ureter and advanced to the left renal pelvis under
haptic feedback. A 26 centimeters x 8 French double-J ureteral stent was placed into the left
ureter. The Boari flap was tubularized using 2 0 and 3 0 Vicryl. A Blake drain was then placed
adjacent to the repair. The Bookwalter was then removed. A soft count was performed that was
correct. The linea alba was closed using 1. PDS in running fashion. Scarpa's fascia was closed
using 2 0 Vicryl in a running fashion. The deep dermal layer was closed using 3 0 Vicryl in
running fashion. The skin was closed using 4 0 Monocryl in a running subcuticular fashion.
Dermabond and sterile dressing was then applied. Patient was extubated taken to recovery room
stable condition. GM 20211104
Preoperative diagnosis: Left ureteral cancer
Postoperative diagnosis: Same
Findings: Approximately 3 centimeter left mid ureteral mass consistent with the ureteral cancer.
Negative frozen section ureteral margin on the third specimen.
Specimens:
1. Left distal ureter
2. Left pelvic lymph node
3. Left distal ureteral margin 1.-frozen section
4. Left distal ureteral margin 2.-frozen section
5. Left distal ureteral margin 3.-frozen section
Drains:
1. 26 centimeters x 8 French double-J ureteral stent without danglers
2. 20 French Foley catheter
3. 15 French Blake drain
Operation performed:
1. Left distal ureterectomy with ureteral reimplant
2. Boari flap
3. Left ureteroscopy
4. Left pelvic lymph node dissection
Description of operation: After informed consent was obtained, the patient was brought back to
operating room and underwent general endotracheal anesthesia. Bilateral TAP blocks were
performed. His abdomen and genitalia were prepped and draped in a sterile surgical manner. A
time-out was performed.
A 20 French Foley catheter was placed. A midline incision was made from the epigastrium to the
pubic symphysis. Dissection carried down to the subcutaneous tissue and the linea alba was
divided. The space of Retzius was entered along with the peritoneum. A Bookwalter retractor
was used to provide exposure. The white line of Toldt was then incised and the descending
colon was reflected anterior medially. The proximal left ureter was identified. The left proximal
ureter was isolated and dissection was carried distally. The ureteral mass was palpable at the
mid ureter. The ureter was then and dissected down to the UVJ. UVJ and bladder was clamped
off using a tonsil. The ureter proximal and distal to the ureteral mass was clipped. The ureter
proximal to the renal mass was then divided. Dissection was then excised and passed off as
specimen for the frozen section. The first ureteral margin was suspicious for malignancy. A
second frozen margin was then given. This came back positive for malignancy. The third margin
returned negative for malignancy. By this point the end of the ureteral margin was approximately
2 centimeters proximal to the common left iliac artery. While waiting for the frozen section to
return, a left pelvic lymph node dissection was performed with the margins of the iliac vessels, the
obturator nerve, the femoral canal, and the iliac bifurcation. The left distal ureter was removed
and passed off as specimen. The bladder margin was closed using 2 0 Vicryl in a running
fashion. A flexible ureteroscope was then placed into the remaining left ureter and advanced to
the renal pelvis. Examination of the ureteral and renal pelvis mucosa showed no abnormalities.
Due to the distance of the distal ureteral margin to the bladder, a Boari flap was required. The
Boari flap was created using the dome of the bladder. The left distal ureter was speculated. The
ureter was anastomosed to the bar flap using 3 0 and 4 0 Vicryl in a interrupted and running
fashion. A guidewire was placed into the left ureter and advanced to the left renal pelvis under
haptic feedback. A 26 centimeters x 8 French double-J ureteral stent was placed into the left
ureter. The Boari flap was tubularized using 2 0 and 3 0 Vicryl. A Blake drain was then placed
adjacent to the repair. The Bookwalter was then removed. A soft count was performed that was
correct. The linea alba was closed using 1. PDS in running fashion. Scarpa's fascia was closed
using 2 0 Vicryl in a running fashion. The deep dermal layer was closed using 3 0 Vicryl in
running fashion. The skin was closed using 4 0 Monocryl in a running subcuticular fashion.
Dermabond and sterile dressing was then applied. Patient was extubated taken to recovery room
stable condition. GM 20211104