# Nephrostomy Tube initial placement. Please Help



## Chlrtrep (Feb 24, 2015)

*Please review case dictation and let me know your thoughts. Question I have is,  how would you code this case. 

Areas of concern are:  final location of tube, ureter dilation (not the normal tract dilation) would you code pre and post injections(angiography)

This is how it was coded in the Lab:
50394, 50395, 74425, 74485, 74475.

Her is case report I appreciate any feedback you may have.*

History:
41-year-old Caucasian female who had a robotic hysterectomy and has a tear involving the distal left ureter. A left ureteral stent was placed but the patient continues to have urine draining into the vaginal cuff and externally. Patient requires diversion of the urine from the left kidney.

Ultrasound guided, fluoroscopically guided left percutaneous nephrostomy drainage catheter placement and ureteral dilatation under moderate IV sedation  


Moderate IV sedation:
Moderate IV sedation was performed using 7 mg of Versed and 50 mcg of Fentanyl. Patient was monitored for an hour and 15 minutes.

Fluoroscopy time: 13.5 minutes.

Sterile barrier technique:
Sterile barrier technique was followed including cap and mask and sterile gown and sterile gloves and large sterile sheet and hand hygiene and 2% chlorhexidine percutaneous for cutaneous antisepsis.

Catheters utilized:
1. AccuStick needle and AccuStick catheter and introducer sheath.
2. 7 and 8 and 9 French dilators.
3. Placement of an 8.5 French hydrophilically coated locking pigtail catheter into the left proximal ureter.

Guidewires utilized:
1. .014 stiff shaft guidewire.
2. 0.35 angled Glidewire with a stiff shaft. Exchange length.
3. 3 mm J stiff shaft 0.35 guidewire.

Contrast:
100 mL of Isovue-300, intravenously.
25 mL of Isovue-300 diluted 50/50 with normal saline in the left drainage catheter.


The indications and risks and benefits and alternatives of the procedure were explained to the patient and her family and their questions answered and informed consent was obtained.

Patient was brought to the angiographic suite and placed prone upon the angiographic table. The patient received Versed and Fentanyl for moderate IV sedation and was monitored for an hour and 15 minutes.

The back was then sterilely prepped and draped. Ultrasound evaluation was performed showing the nondilated left kidney. The left ureteral stent was not well visualized under ultrasound. The left renal pelvis could be identified. Patient was then injected with 100 mL of Isovue-300 intravenously. This allowed under fluoroscopy for the collecting system to be visualized along with a left ureteral stent. Images were obtained both with ultrasound as well as with fluoroscopy confirming the anatomy of the left kidney.

Next, utilizing a 22-gauge spinal needle 1% lidocaine without epinephrine was then locally infiltrated into the skin and subcutaneous tissues and left renal parenchyma. Next, a 22-gauge acupuncture needle was advanced down under ultrasound. Despite appearing within the renal pelvis on ultrasound, the needle did not appear to be in the left renal pelvis under fluoroscopy with IV contrast. The 0.14 guidewire would not advance easily into the left ureter. For this reason, the needle was withdrawn and a another site was attempted. Again 1% lidocaine without epinephrine was locally infiltrated into the skin and  subcutaneous tissues. Under ultrasound guidance and with fluoroscopy guidance again an attempt was made to traverse into the left renal pelvis. This did not occur and the 0.14 guidewire would not easily advanced down.

Next, under fluoroscopy utilizing a straight posterior approach the 22-gauge spinal needle was advanced down towards the left kidney. 1% lidocaine without epinephrine was then locally infiltrated into the skin and subcutaneous tissues and left kidney.

Next, the  21-gauge acupuncture needle was advanced down under fluoroscopy and seen to enter into the left renal pelvis. This was seen extending into what appeared to be a posterior middle calyx. Once this was in position then the 0.14 wire could be advanced down adjacent to the left ureteral stent. More 1% lidocaine without epinephrine was locally infiltrated into the skin and subcutaneous tissues and a small incision was made in the skin using an 11 blade. Next, the 0.14 guidewire was withdrawn and contrast was injected through the introducer sheath showing that the introducer sheath was well-positioned within the left ureter with no extravasation outside of the left ureter. The inner dilator later was removed and a 0.35 angled Glidewire with a stiff shaft, and exchange length, was advanced down. This was seen extending down the left ureter and into the urinary bladder. Next, the introducer sheath from the acupuncture needle was withdrawn and a 7 and 8 and 9 French dilator used to dilate up the tract under fluoroscopy. Once the been accomplished then an 8.5 French hydrophilically coated locking pigtail catheter was advanced down into the left ureter.

Next, an attempt was made to form the pigtail catheter within the left renal pelvis. There was not enough room within the left renal pelvis to completely lock the pigtail catheter, therefore an attempt was made with the 3 mm 0.35 J guidewire to advance the catheter back down into the left ureter. This did not traverse through the catheter and the guidewire tended to exit through one of the sideholes that was not within the left kidney at this time. The 0.35 angled Glidewire was then manipulated down into the left ureter and the catheter further advanced down into the left ureter. The guidewire was withdrawn and the locking pigtail catheter partially locked with just a single tight coil identified just within the calyx of the mid aspect of the left kidney. Once this had been performed, then contrast was injected that showed no extravasation and excellent draining of the left renal pelvis and proximal left ureter. Images were obtained confirming the location of the catheter.

Next, the catheter was sutured to the skin using 2-0 silk. Sticky material was applied to the skin along with Steri-Strips. A Percu-Stay dressing and along with a Tegaderm dressing was then also applied. The catheter was draining slightly blood-tinged urine post placement. The patient tolerated the procedures well and there were no immediate complications. Patient was returned to outpatient surgery for recovery.


The patient was given a prescription for Norco 10/325, a total of 30 tablets, to take 1 tablet p.o. q.6 hours p.r.n. pain. No refills. Generic can be prescribed.


Successful ultrasound-guided and fluoroscopically guided left percutaneous nephrostomy drainage catheter placement with no immediate complications. Please see the above dictation


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## Jim Pawloski (Mar 1, 2015)

Chlrtrep said:


> *Please review case dictation and let me know your thoughts. Question I have is,  how would you code this case.
> 
> Areas of concern are:  final location of tube, ureter dilation (not the normal tract dilation) would you code pre and post injections(angiography)
> 
> ...




I would code 50390/ 74425 and 50392/ 74475.  There is no tube in place to get 50394, and this is not access for removal of a stone, so 50395 does not qualify either.
Thanks,
Jim Pawloski, CIRCC


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## Chlrtrep (Mar 9, 2015)

Thanks This is what I thought as well however the Radiologist said it was more involved then the codes I presented to him.  I said yes it was more involved but this is what can be coded for my point of view.


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