# Cystoscopy with right ureteral stent placement.



## MUS (Nov 4, 2019)

Good Morning,
Can anyone help with the procedure codes.
I am split between these two codes CPT 52332-RT and 50081. As per conclusion there were no removable stones. I'm confused.

PREOPERATIVE DIAGNOSIS:
Right renal calculi.
POSTOPERATIVE DIAGNOSIS:
Right renal calculi.

PROCEDURE:
1. Right antegrade percutaneous nephroscopy.
2. Right retrograde diagnostic ureteroscopy.
3. Right percutaneous renal access.
4. Cystoscopy with right ureteral stent placement.
5. Radiologic supervision and interpretation 

INDICATIONS FOR PROCEDURE:
The patient is a 62-year-old female with bilateral kidney stones.  On the
right, she has several stones including 1 that appeared to be 11 mm and
another one that appeared to be 12 mm as well as adjacent millimetric stones,
total stone burden greater than 2 cm.  The patient was counseled on options
for management including risks, benefits, and alternatives, and after due
cosideration, she wished to proceed with right percutaneous nephrolithotomy.

DESCRIPTION OF PROCEDURE:
The patient was identified and consented and marked in preoperative holding
area.  She was given opportunity to ask questions, which were answered to her
satisfaction.  She was brought to the operating room and given prophylactic IV
antibiotics.  She was placed under general anesthesia on the stretcher.  She
was positioned in frogleg and then the genitalia were sterilely prepped and
draped.  A time-out was taken to verify correct patient, procedure, site, and
laterality.  We then began the procedure with cystoscopy, passing the rigid
cystoscope into the bladder and examining the bladder.  There were no lesions.
The right ureteral orifice was identified and cannulated with a Sensor wire,
which was passed up to the right renal collecting system without difficulty.
The 5-French Pollack catheter was then also passed over the wire up to the
collecting system.  The scope and wire were then removed leaving the Pollock
in place and then a Foley catheter was placed in the bladder to which the
Pollock was secured with a 0 silk tie.  The patient was then carefully turned
into the prone position on the split-leg operating table with all pressure
points carefully padded and all extremities in neutral position.  The
patient's right flank and back and the genitalia including the catheters were
all sterilely prepped and draped.  A second time-out was taken for this
portion of the procedure.  We then performed fluoroscopy of the right side of
the abdomen, which revealed the aforementioned radiopaque calculi.  We
exchanged the Pollack catheter over wire for a 7-French ureteral occlusion
balloon catheter and instilled contrast into the collecting system as well as
 few mL of air to delineate the posterior calyces.  As mentioned, the kidney
appeared to be malrotated.  The upper pole calyx was above the 11th rib, and
therefore, we performed our puncture into the next available upper interpolar
calyx using an 18-gauge two-part trocar needle, which was advanced under
biplanar fluoroscopy.  We were able to confirm access of the needle into the
collecting system and then passed a Sensor wire through the needle and into
the collecting system and down the ureter into the bladder.  We then made a 1
cm incision on the needle and then dilated the tract with coaxial fascial
dilators over the wire under fluoro up to 16-French and then used Amplatz
dilator to place a safety wire and dilate up to 18-French.  I then attempted
to pass the flexible nephroscope over the working wire to examine the
collecting system before fully dilating the collecting system, but was unable
to get the scope to go into the kidney.  Therefore, we used the Amplatz system
to dilate the tract up to 24-French, which was the smallest sheath available.
Once this was done, we advanced the flexible scope into the working sheath and
into the kidney and then did a pannephroscopy with findings as noted above.
as mentioned, we also backloaded a flexible ureteroscope retrograde over a
wire placed through the occlusion balloon catheter and did retrograde
diagnostic ureteroscopy examining all the calices with the flexible
ureteroscope under direct vision guided with fluoroscopy and contrast
injection and came to the conclusion that the stone burden seen was not
contiguous with the collecting system.  At this point, it was decided to
conclude the procedure as there were no removable stones and we deployed a 6-
French double-J stent over the retrograde wire with the proximal curl in the
upper pole calyx under fluoro and the distal curl in the bladder.  The string
was left on.  We then removed the working sheath from the flank and passed a
16-French Councill catheter to act as a nephrostomy tube over the remaining
wire and positioned this in the collecting system, confirming with contrast
injection through the tube.  The tube was secured to the skin and the tract
and skin were anesthetized with 0.25% Marcaine plain.  We then reapproximated
the remaining portion of the incision with interrupted 4-0 chromics and placed
a dressing and then the patient was carefully turned back into the supine
position on the stretcher, where she was awakened and extubated.  She
tolerated the procedure well and there were no complications.  The patient was
taken to recovery room.


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## Ritika (Nov 12, 2019)

I will code it as 52332-RT as stent was placed at the end. and as Ureteroscopy was also done for diagnostic purposes I will code it as 52351-RT.


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## MUS (Nov 20, 2019)

Thank you so much Ritika
 I appreciate your help.


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