# PCNL with nephrostogram



## umcanes4 (Jul 29, 2016)

Heya. Looking for some guidance on the op report below. Thanks for the help, it is really appreciated. 

Would you code as:
50081
50693
52000
74425


_NAME OF OPERATION:
1.  Right percutaneous nephrolithotomy with CyberWand.
2.  Antegrade nephrostogram with intraoperative reading.
3.  Stone extraction.
4.  Stent placement.
5.  Cystoscopy.
.
INDICATION FOR OPERATION:   Mr. Vogt presented to us with an enlarging kidney stone measuring greater than 2 cm.  We discussed all the options and he agreed to proceed with PCNL.  He had access placed earlier today.  We discussed all the risks include bleeding, infection, pain, need for repeat procedures, injury to surrounding structures, and requirement of a long-term catheterization.  Patient signed consent and he was then brought to the room.
.
DESCRIPTION OF OPERATION:  After informed consent was received, patient was brought to the operating room, placed in supine position.  Anesthesia was induced.  Once the patient was asleep, he was placed in a prone position.  He already had access into his right kidney.  We prepped and draped around the access in a standard fashion.  At this point in time under fluoroscopy we could visualize large stone.  We then used a NephroMax balloon to dilate the tract.  Once we got in we placed our sheath in and then entered with the nephroscope.  We could then visualize the stone.  We then took the CyberWand and start to fragment the stone.  The stone was very hard in composition.  We then proceeded to remove the pieces.  On fluoroscopy still appeared to have a significant portion of his stone gone, but there was probably a 6 to 7 mm stone in the lower pole.  I shot an antegrade nephrostogram and also used a cystoscope through the tube tract and still could not visualize this stone that was left, but the majority of stone burden was cleared.  We then had to place a new wire down into the ureter for access.  We were able to get an open-ended catheter over it as well and then confirmed that it was definitely in the ureter.  At this point in time, the wire was kept in place.  We then placed a 6 x 26 double-J stent down the right ureter, but it did not appear to be coiling like we wanted it to in the bladder.  It had migrated down into the urethra.  We tried to manipulate but still could not.  Therefore, the stent was kept where it was in the kidney.  We then removed all instrumentation.  The tract was closed with FloSeal and then the skin was closed using 0 chromic suture intermittently.  The right side incision was then appropriately addressed.  He was still under anesthesia and placed now back in the supine position.  His genitals were prepped.  Then I performed a cystoscopy to see exactly where the stent was distally.  The curl did was in the prostatic urethra.  Using flexible cystoscope, I was able to navigate it back into the bladder.  It was coming out from the right ureter.  _


----------



## emcee101 (Jul 29, 2016)

Codes 50081, 50693 and 74425 should all be good with the appropriate modifers (RT, 51, etc.). I question if this is the appropriate use for 52000, since the cysto is not an integral part of the PCNL & stent and was done to check/correct the stent placement. The cysto was not performed because of a surgical complication, but rather to check and correct the stent, which was not placed correctly and/or did not coil correctly. I would not not bill for the cysto because ultimately it is not the insurance company or patient's responsibility to pay for an additional "quality check" procedure. Others may disagree and bill for it though. There is no CCI edit in place that would prevent it from being billed/paid as far as I can tell. Hope this helps!


----------



## umcanes4 (Jul 29, 2016)

Awesome.


Thanks


----------



## JEYCPC (Jul 29, 2016)

I agree that the cysto is not appropriate to bill when used to check the work.  

Also 50081 includes the stenting so 50693 should not be billed either.  Lastly, in order to bill for 74425-26, there needs to be separate documentation 
with the findings specified.

Just my way of looking at it.


----------



## emcee101 (Aug 1, 2016)

JEYCPC said:


> I agree that the cysto is not appropriate to bill when used to check the work.
> 
> Also 50081 includes the stenting so 50693 should not be billed either.  Lastly, in order to bill for 74425-26, there needs to be separate documentation
> with the findings specified.
> ...




Correct on all accounts. Thanks for filling in what I missed JEYCPC!


----------

