Sample Nephroureteral Catheter Placement Report for Medical coders

Report 1

BILATERAL NEPHROSTOGRAMS PLACEMENT OF NEPHROURETERAL CATHETERS

MODERATE CONSCIOUS SEDATION, FLUOROSCOPY CAN ULTRASOUND GUIDANCE AND UTILIZATION OF A STERILE SURGICAL TRAY.:

INDICATION: Bilateral nephrolithiasis

TECHNIQUE: Ultrasound and fluoroscopy guidance, fluoroscopy time is 14.7 minutes

COMPARISON: None.

FINDINGS:

Having obtained informed consent prepping and draping the flanks in the usual aseptic fashion 1% lidocaine was utilized for local infiltration. Access to the lower pole collecting system of the left kidney is obtained utilizing ultrasound guidance an AccuStick system. Wire and catheter advanced into the collecting system of the left kidney followed by placement of a wire and a 4 French catheter into the bladder.

Attention was then turned to the right kidney. Ultrasound revealed moderate hydronephrosis of the right kidney. Access to the midpole of the right kidney is obtained utilizing ultrasound guidance. This was then followed by a nephrostogram. A nephrostogram demonstrates at least 2 parapelvic cysts within the left kidney. There is a partially duplicated collecting system of the left kidney. There is significant resistance to passage of the wire and catheter through the proximal right ureter. Once access was secured distally wire and catheter were advanced in the bladder followed by placement of a 4 French Kumpe catheter over a Amplatz wire into the bladder. The patient tolerated the procedure well. There are no immediate complications. Permanent fluoroscopy images are taken and stored.

IMPRESSION:

1. Uncomplicated placement of bilateral nephroureteral catheters and wires as discussed above.

50694-50 Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; new access, without separate nephrostomy catheter

Report 2

RIGHT C5-C6 TRANSFORAMINAL EPIDURAL STEROID INJECTION WITH FLUOROSCOPY:

INDICATION: Neck pain

TECHNIQUE: Fluoroscopy guidance fluoroscopy time is less than 1 minute

COMPARISON: None.

FINDINGS:

Having obtained informed consent prepping and draping the neck in the usual aseptic fashion 1% lidocaine was utilized for local infiltration. Access to the transforaminal epidural space on the right is obtained utilizing fluoroscopy. A few cc of contrast was injected to perform a epidurogram thereafter which an admixture of dexamethasone and bupivacaine was injected. The patient tolerated the procedure well without complications. Permanent fluoroscopy images are taken and stored.

IMPRESSION:

1. Uncomplicated transforaminal epidural steroid injection right C5-C6 level with fluoroscopy

CPT-64483