Urology Coding Alert

How would you report this procedure?

Test your operative report interpretation skills with this case study from a Urology Coding Alert subscriber in Illinois.

Preoperative diagnosis: Bilateral ureteral trauma

Postoperative diagnosis: Bilateral ureteral trauma

Procedure: Bilateral ureterolysis and bilateral ureteral-ileal anastomosis

Drains: Bilateral single J ureteral stents and 10-mm Jackson-Pratt drain

History: Patient is a 63-year-old man undergoing colorectal surgery. There was extensive scarring and during the course of the colorectal surgery, it was discovered that both ureters had been transected from the patient's existing ileal loop which had been placed in December 2011 following radical cystectomy for bladder cancer.

Operative Procedure: With the patient asleep and with the abdomen open from the colorectal surgeon, I was able to scrub and enter the operative field. The ileal loop was identified including a small stump of the right transected ureter noted and the left ureter appeared to have been transected at the level of the anastomosis. The right ureter was easily identified and did appear to be somewhat dilated. Gentle dissection was done and the lumen was identified. The lumen was catheterized with 5-French whistle-tip catheter and this sewn into place with a 3-0 chromic suture. Careful blunt and sharp dissection was then carried out to free the ureter for approximately 6-8 cm. This proceeded quite slowly because of the extensive scarring and the need to avoid damaging the ureter including its blood supply. Care was taken not to injure the great vessels in the pelvic area.

The left ureter was able to be identified with some gentle dissection. The lumen was also identified and a similar 5-French whistle-tip catheter was placed in this and sewn into place with a 3-0 chromic suture. Again, a very slow, methodical dissection was carried out to free the left ureter for a distance of 6-8 cm. The cut ends of both ureters were then transected. There did appear to be good urine flow and the mucosa appeared adequately vascularized on both sides. The loop was again identified and the site of the left ureteral ileal anastomosis was oversewn with a 3-0 chromic suture. The stump of the right ureter still present in the ileal loop was suture ligated with a 3-0 chromic stitch.

At this point new areas were picked out on the base of the ileal loop and first on the left side, a small ileotomy was made. Holding sutures of 3-0 chromic were placed in both ends of the ileotomy and then the left ureter brought over to this. A grooved director was placed in the ureter and the ureter was spatulated for a short distance. A 4-0 chromic suture was then placed in the apex of the ileotomy and also in the apex of the ureter. This was then sewn down into place and a single layer closure using interrupted sutures of 4-0 chromic was then begun.

Once the back wall had been completed, a single J ureteral stent with wire inserted was passed through the stoma and out through the anastomosis. It was then able to be guided down the left ureter and up into the left renal pelvis to a distance of approximately 24 cm. The wire was then removed and the slack taken out of the stent.

The anterior wall of the anastomosis was then completed with interrupted sutures of 4-0 chromic. A slanted cut was made in the end of this stent. Similarly on the right side, an ileotomy was made in the base of the ileal loop and a similar ureteral ileal anastomosis was performed using again a single J stent.

Once both anastomoses were in place, additional sutures of 4-0 chromic were used to reinforce the anastomosis between the ileum and the ureters. At this point hemostasis appeared excellent and the rest of the procedure was to be completed by the colorectal surgeons with the addition of placing a 10-mm Jackson-Pratt drain at the area of the ureteral ileal anastomoses.

In the recovery room the patient will undergo a KUB to ascertain placement of the stents.

Your turn: How would you code this procedure?

Answer: You should report the following codes for this case:

Report 50800 (Ureteroenterostomy, direct anastomosis of ureter to intestine) for the reimplantations of the ureters into the bowel. Since the urologist performed the procedure bilaterally, append modifier 50 (Bilateral procedure) to 50800. Attach 867.2 (Ureter injury without mention of open wound into cavity) as a primary diagnosis and 998.2 (Accidental puncture or laceration during a procedure) as a secondary diagnosis.

Report 50715 (Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis) for the ureterolysis. Since the urologist performed the procedure bilaterally, append modifier 50 to 50715. You will also need to append modifier 59 (Distinct procedural service) to indicate that the two procedures were separate. Note that Medicare and many other payers bundle 50715 into all ureteral surgeries and will deny payment for this surgery when billed with a ureteral surgery. Attach diagnostic code 593.89 (Other specific disorders of kidney and ureter, periureteritis).

Bonus: Want your complicated operative report featured in Code This!? Send it to Leesa at leesai@codinginstitute.com.