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Urology Coding Alert

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Scope Out the Proper Coding for this Surgery

Published on Tue Mar 13, 2012

How would you report this procedure?Test your operative report interpretation skills with this case study from a Urology Coding Alert subscriber in Springfield, Ill. Indication: Patient has history of a neobladder with a stone in distal right ureter. He had a previous stent placed. He had a right PCN access placed yesterday. Operative Procedure: Patient prepped and flexible cystourethroscopy was performed. Bladder neck was open and the neobladder was inspected -- no stones in the neobladder. I could not identify the stent in the neobladder. I placed a 16F. coude-tipped catheter. Patient turned prone. Right flank prepped. Radiologist came in and placed working access port. He placed a glidewire down into the neobladder. Rigid renal endoscopy and ureteroscopy performed antegrade. Right renal pelvis and proximal and distal ureter normal, no stones seen. I was able to go right into the neobladder to see the Foley tip balloon. Scope passed twice up [...]
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