# Help with coding Percutaneous nephrolithotripsy



## fortned (Aug 27, 2013)

I sure get confused on what codes to use on these cases. I was trained prior to use 50081, 50395 and 74485. But with this case below it appears he did something extra that I am missing to code. Appreciate anyones help.

Op Note:

OPERATIONS:
1. Tract dilatation under fluoroscopy.
2. Percutaneous nephrolithotripsy, 22 modifier, extensive removal.
3. Secondary access tract placed by Urology, needle access to the kidney under fluoroscopy to the upper pole.
4. Tract dilatation of that.
5. Percutaneous nephrolithotripsy with removal of greater than 5-cm upper pole stone disease, flexible nephroscopy along with antegrade ureteral stent placement x2, and nephrostomy tube placement x2 with nephrostograms etc., with intraoperative fluoroscopy

After informed consent, he was brought to the OR. He was placed under general endotracheal anesthesia, flipped prone, padded appropriately, given his body habitus changes, and had a Foley catheter indwelling. He was prepped and draped in the usual sterile fashion including his flank, tube, etc. We then accessed _____ureteral, passed a wire down under fluoroscopy and exchanged this out to two wires. We dilated his tract to 30-French using a NephroMax balloon, placed a sheath into the kidney and then left a working and safety wire. Through this, we then performed percutaneous nephrolithotripsy and removed massive amount of stone. Basically, he had a huge stag aggregate volume probably over 15 cm of stone. We were able to remove the entire pelvic stone and many of the calices were accessible at the mid pole but the upper pole, which had another probably 6 to 7 cm of stone, and it was not accessible. I, therefore, after consideration, placed a secondary access using 18 gauge diamond-tip needle under two planes of fluoroscopy technique into the upper pole. I placed down a glidewire. I was able to steer this down to the bladder and then switch out to two superstiff wires, dilated a secondary tract, placed in a NephroMax sheath to 30 French and then left the working and safety wires. We then went in through there and removed the entire upper pole stone. At the conclusion, we attempted to get into his lower pole stone which was the only one remaining; however, I was unable to get to this from either of these accesses since there was a lot of swelling and bleeding from kidney at that point; therefore, we decided to stop, placed in two 22-French nephrostomy tubes with access catheters through these down the ureter. Each of these was inflated with 2 to 3 mL of air and positioned appropriately with nephrostograms, etc., and sewed to the skin. All of the wires, etc., were removed. A Foley catheter was left indwelling. He will be observed postoperatively at high risk for infection or other problems.


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