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Bladder Dilation

  1. #1
    Default Bladder Dilation
    Medical Coding Books
    16 French CYF Olympus flexible deflectable cystourethroscope was introduced through the external urethral meatus, along the lumen of the urethra into the bladder. Inside of the urethra and bladder were visualized. All the bladder walls, dome, and the trigone were visualized. The tip of the scope was also flexed and the internal urethral meatus and the surrounding area were visualized. Cystourethroscopy findings are as follows: Cystourethroscopy findings: Anterior urethra: Normal. Area of the external urethral sphincter: Normal Verumontanum: absent due to past Radical Prostatectomy Posterior Urethra: absent due to past Radical Prostatectomy. Bladder neck: Normal Right ureteral orifice: Normal with clear urinary efflux. Left ureteral orifice: Normal with clear urinary efflux. Bladder mucosa: Normal All the bladder walls, dome, and trigone were visualized. There was no evidence of bladder mucosal tumor grossly. There was no evidence of calculus. After this, Tight retrograde ureterogram was performed with 30 % contrast and Rutner wedgw tip catheter. Which sggested narrowing of right mid ureter. After this I had to dilate intramural part of right ureter with 0.035 inch gauge glide wire which was introduced through the right ureteral meatus along the right ureteral lumen into the right renal pelvic area. Over the glide wire, 8 F flexible, deflectable ureteroscope was advanced with C-arm fluroscopic guidance. Inside of the right ureter was visualized. Right Ureteral Findings are as follows: Randall's Plaques at all papillas of the right kidney. No evidence of obstruction, tumor. Crossinf of ureter at bifercation of right common ileac vessels causing narrowing of ureter but no obstruction. Ptosis of right kidney

    I can't seem to find the right code, can one of you experts help me out. It doesn't look like he used a balloon for the dilation.

  2. Default
    Looks to me like he dilated in order to introduce the ureteroscope. I think 52351 and 74420, 26 (depending on who owns the equipement and who read the report).

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