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Thread: balloon angioplasty uretero-enteric anastomosis.

  1. #1

    Default balloon angioplasty uretero-enteric anastomosis.

    AAPC: Back to School
    How to code balloon angioplasty uretero-enteric anastomosis.

    61-year-old female status post Indiana pouch creation status post
    left nephroureteral catheter referred for dilatation of the
    ureteral anastomotic stricture and exchange of the nephroureteral
    stent placement.


    Following informed consent the patient was placed in the prone
    position and the right flank prepped and draped in a sterile
    fashion. Intravenous versed and Fentanyl were administered for
    conscious sedation. Physiologic monitoring was performed
    throughout the procedure. Intravenous antibiotics were
    administered prior to the procedure.

    The previously placed catheter was prepped and draped in a sterile
    fashion. Contrast was injected and digital images were obtained.
    The catheter was exchanged over a guidewire for a 7-French
    vascular sheath. Contrast was injected and imaging of the distal
    left ureteral enteric anastomosis was performed. These images
    demonstrate a moderate-grade narrowing of the ureteral enteric
    anastomosis. This narrowing was dilated to 8 mm with a prolonged

    The tract was dilated to 10 F and an 10F, 24 cm long
    nephroureteral catheter placed with its distal loop forming in the
    bladder and its locking loop formed in the dilated right renalpelvis.

    The catheter was secured to the skin with adhesives and attached
    to gravity drainage. The patient tolerated the procedure well and
    left the department in satisfactory condition.


    There is high grade narrowing of left uretero-enteric anastomosis.
    This was treated with balloon angioplasty a 8 mm and then stented
    with a 10-French nephroureteral catheter placed as described


    1. Moderate grade distal left uretero-enteric stricture treated
    with balloon dilatation to 8mm .

    2. Exchange of previously placed 8-French nephroureteral catheter
    for a new 10-French, 24-cm long nephro ureteral catheter.
    Shirley CPC,CPC-H

  2. #2


    SIR states that ureteral balloon dilatation can be coded as 50553 or 53899 based on your practice's understanding of the change in the CPT introductory language that took place in 2002 and the CPT and CMS instruction to use the most closely descriptive endoscopic codes.

    Diane Huston, CPC,RCC

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