Sample Coded report of URETEROSCOPY CPT code

Pre-op Diagnosis: Renal stones, Recurrent UTI, solitary Left Kidney

 Post-op Diagnosis: Same, Bladder lesion overlying bladder neck and LEFT Ureteral orfice

Proc. Description(s) & CPT Code(s): LEFT URETEROSCOPIC LITHO, STONE EXTRACTION:

BLADDER BIOPSY; URETEROSCOPY CYSTOSCOPY WITH STENT PLACEMENT: 

Anesthesia: General

Complications: none

Findings: 1.  Stones mostly matrix material with small pebble like consistency. Removed with prolonged basketing and irrigation.

2.  Papillary lesion overlying left bladder neck and LEFT UO. Cold cup biopsy obtained.  Lesion is 2.5 cm left bladder neck, overlying left trigone and ureteral orifice small satellite lesion noted.  Unsure of malignancy or inflammatory.
3. Sig Erosion of penile urethra Wide patent Bladder neck.
4. Nephrostomy removed during procedure. 

Technique: After informed consent was obtained, the patient has taken back to the operating room.  Once appropriate preoperative antibiotics were administered and general anesthesia was achieved, the patient was placed in a dorsal lithotomy position.  The genitals were prepped and draped in normal sterile fashion.  A time-out was performed which identified the patient with 2 patient identifiers in addition to the site of surgery.

 Twenty-two French cystoscope was assembled and placed into the patient’s bladder per urethra. Survey of the bladder revealed a significantly contracted bladder evidence of papillary lesion questionable inflammatory change versus malignancy identified over the left ureteral orifice with an indwelling double-J stent there was no right ureteral orifice identified.  Bladder neck was widely patent there was no evidence of urethral stricture disease identified on cystoscopy.  The nephroureteral stent which was identified was grasped with alligator grasper pulled through the patient’s urethral meatus.  A safety wire was then placed.  The nephroureteral stent was subsequently removed successfully.  

A 0.35 glidewire was advanced alongside the 1st wire placed.  A 12 x 14 French access sheath was then easily advanced to the level of the left ureteropelvic junction.  The wire and the obturator were then withdrawn.  Flexible ureteroscopy was performed which revealed significant amount of matrix-like material within the kidney itself all blood clot identified from the previous nephroureteral stent placement the stones were not large enough to require laser lithotripsy however there was significant enough to require basketing.  Prolonged basketing was performed the lower pole mid pole calices.  

Once clinically significant stone burden has been removed after retrograde pyelogram was performed to opacify the collecting system systematic survey was performed there was only dustlike particles identified the midpole calices otherwise no clinically significant stone burden remaining on KUB or direct visualization.  The access sheath and the scope were then withdrawn under direct vision the ureter appeared widely patent without evidence of injury.  A 6 French by 22 cm double-J stent was subsequently deployed with strings attached adhered to the patient’s mons pubis.  

Cystoscope was then reassembled the lesions identified within the bladder were biopsied using cold cup biopsy and fulgurated.  Lesions were measuring greater than 2 cm if positive for malignancy will require a staged TURBT.  Once hemostasis was confirmed the patient’s bladder was decompressed with an 18 French Foley catheter secured with 15 cc of sterile water the patient was awakened from anesthesia transferred to recovery room satisfactory condition.

52356 CYSTO/URETERO W/LITHOTRIPSY andINDWELL STENT INSRT; (-LT Left side of body)

52354 CYSTO/PYELOSCOPY BXand/FULGURATION PELVIC LESION

52352 CYSTO W/URETEROSCOPY W/RMVL/MANJ STONES; (-XU Unusual Non-Overlap Svc)

N20.1 – Calculus of ureter

N39.0 – Urinary tract infection, site not specified