# Bilateral nephrostogram w/ Exchange of nephroureterostomy to percutaneous nephrostomy



## MCCONKEYT (May 2, 2016)

This was a bilateral procedure and we have had much discussion over how to bill this to Medicare to ensure we are reimbursed correctly. 

50693 - RT                         
50693 - LT

or       50693 - 50 bill as 1 unit and double our price?

Medicare doesn't like RT/LT.   Below are the notes:


Percutaneous nephroureterostomy exchange to percutaneous nephrostomy
bilaterally under fluoroscopic guidance

Exam:
1. Bilateral nephrostogram
2. Exchange of nephroureterostomy to percutaneous nephrostomy
bilaterally

Clinical indication: Bladder pain. Rectal cancer.

Consent: The procedure, risks, benefits, and alternatives were
discussed with the patient, and all questions were answered. Informed
consent was obtained verbally and in writing.

Nursing/medications: Continuous cardiorespiratory monitoring was
provided throughout the examination. Moderate conscious sedation at
level 3-4 was obtained with versed and fentanyl by a trained
independent observer under the supervision of the performing provider.

Procedure:
The patient was positively identified, taken to the angiography suite,
and positioned prone on the fluoroscopy table. Timeout was performed.

Scout film demonstrated the existing bilateral nephroureterostomies in
expected positions.

The bilateral flanks and existing catheters were prepped and draped in
the usual sterile fashion using all elements of maximal sterile
barrier technique including cap, mask, hand hygiene, sterile gloves,
sterile gown, 2% chlorhexidine skin preparation, and large sterile
drape. Local anesthesia was provided by administration of lidocaine
1% solution.

Through the existing nephroureterostomies, simultaneous bilateral
nephrostograms were performed demonstrating proper positioning of the
catheters and no hydronephrosis.

Catheters were simultaneously removed over 0.035" wires in the usual
fashion. A new 8-French nephrostomy catheter was advanced into each
renal collecting system under fluoroscopy bilaterally, simultaneously.

Wires and stiffeners were removed. Completion nephrostograms
demonstrated the nephrostomies to be in proper position within the
renal pelvis bilaterally. The catheters were locked into place,
sutured to the skin, and connected to bag/gravity drainage. Sterile
dressings were applied.

Complications: None immediate. Patient was transferred to the holding
area in stable condition for further monitoring.

Plan: Keep open to gravity drainage. If no surgical intervention in
planned, recommend exchange of nephrostomies in 6-8 weeks.

Fluoroscopy time: 1.0 minute

Impression: Successful exchange of bilateral nephroureterostomies to
percutaneous nephrostomies as detailed above.

Thank you for your help!!!


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