# need help - Six stones ranging in size from 2 cm to 6 cm



## elainehopf (Mar 25, 2015)

need thoughts on the following :
PREOPERATIVE DIAGNOSIS:  Continent pouch stones.
POSTOPERATIVE DIAGNOSIS:  Continent pouch stones.
PROCEDURE PERFORMED:
1.  Laparotomy with open cystolitholapaxy in the Indiana pouch.
2.  Placement of cystostomy tube in the continent pouch.
FINDINGS:  Six stones ranging in size from 2 cm to 6 cm.  These were all
removed.  A 20-French tube was placed into the Indiana pouch.
INDICATION FOR PROCEDURE:  found to have very large bladder stones that had difficulty catheterizing. 
He was treated with appropriate antibiotics and selected to undergo open
stone extraction.
PROCEDURE IN DETAIL:  The patient was brought to the Operating Room on
March 16, 2015.  Preoperative antibiotics were given.  Once the airway was
secured and sufficient anesthesia was achieved, his abdomen was prepped and
draped in sterile usual fashion.  We placed a 12-French catheter into his
catheterizable stoma.  We made a 5 cm incision at the level of the 11th rib
lateral to the continent stoma.  Electrocautery was used to carry
dissection down to the level of the fascia.  The fascia was opened and we
instilled blue dye irrigation into the pouch and this was identified with a
finder needle.  We then opened the Indiana pouch after placing stay
sutures.  We extracted the stones.  There were 6 stones ranging in size
from 2 cm to 6 cm.  The stones were removed in their entirety and 1 stone
was sent for culture.  We then irrigated copiously.  We then placed a 20- 
French Foley catheter through the abdominal wall and placed a drainage tube in 
the lateral area of the Indiana pouch.  We then placed the catheter into the 
Indiana pouch and inflated the balloon with 20 mL and tied a purse-string down.
 We then closed the Indiana pouch using 3-0 Vicryl in 2 layers.  We extended
the  Indiana pouch using irrigation with no evidence of extravasation.  It was 
irrigated copiously once again and we closed the fascia using #1 Maxon in a 
running fashion.  The subcuticular fat was

reapproximated using 3-0 Vicryl and the skin was closed using 4-0 Monocryl.
 The patient tolerated the procedure well, was extubated in the operating
room and brought to recovery room in stable condition.
I was present and participated in all aspects of the case.

 Im thinking 50060 ...


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## emcee101 (Mar 26, 2015)

50060 is a nephrolithotomy, which is the percutaneous removal of a stone in the kidney. Your doctor removed the stones from an ileal neobladder so 50060 would not work. 

This is one of the harder situations that I have seen in a long time. I've thought about it for the last few hours, and consulted a few coworkers, both coders and nurses to get their advice as well. In the end I think you can go one of two ways. The more aggressive way would be to bill for 51050 - cystolithotomy but this claim may be denied because it is a bladder code and your patient does not have a bladder. You could also bill an unlisted code - 49999 unlisted proc abdomen, peritoneum and omentum - and follow the insurance companies instructions for sending a paper claim. I would send the op note along with a letter referencing CPT 51050 to show that the work performed was similar.


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## acalce (Mar 27, 2015)

How about 52317-22, 52318-22?


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## elainehopf (Mar 30, 2015)

Thank you both .....


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## emcee101 (Mar 30, 2015)

elaine. just a caution to you, 52317 or 52318 would not be appropriate because this was not a litholipaxy since the stones were not crushed or fragmented and this was not done transurethrally.   

I will also ammend my own advice and would probably go with the unlisted CPT from the urology series, 53899 sine the stones were urologic in nature.


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## nateich (Mar 30, 2015)

An article copied from SuperCoder, its an older article but it may help;

Reader Questions: Include 44300 When Doctor Places Drainage Tubes
- Published on Fri, Sep 23, 2005


Question: How should I code an open removal of stones from an Indiana pouch? The operative report states that the previous midline incision was opened just cephald to the umbilicus, and dissection was taken down through this area carefully into the abdominal cavity. The doctor identified the pouch. He then placed stay sutures and opened the pouch. The urologist readily identified the two large stones and removed them intact. He introduced a  22-French cystoscope through the incision in the pouch and carefully inspected and irrigated the pouch interior.


Wisconsin Subscriber


Answer: Coding for the removal of the calculi depends on the segment of bowl or predominate segment used for the diversion and the abdominal pouch. If the predominant segment used for the diversion is colonic (large bowl), report 44025 (Colotomy, for exploration, biopsy, or foreign body removal). If the predominant segment used for the diversion is ileum (small bowl), report 44020 (Enterotomy, small intestine, other than duodenum; for exploration, biopsy, or foreign body removal).

You should report diagnosis code 936 (Foreign body in intestine and colon) for the stone in the bowl segment.

If your urologist placed a drainage tube in the bowl segment after he opened the bowl and removed the stone, also report 44300 (Enterostomy or cecostomy, tube [e.g., for decompression or feeding] [separate procedure]).


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