Urology Coding Alert

Question: Can you please help me code the following operative report?

POSTOPERATIVE DIAGNOSES:

1. Foreign body in ileal conduit is a vascular staple.

2. Left hydronephrosis, status post radical cystectomy with indwelling stent.

3. Vaginal discharge.

OPERATION PERFORMED :

1. Looposcopy of an ileal loop with removal of foreign body in conduit (vascular staple).

2. Left stent exchange under fluoroscopy with intraoperative interpretation, less than 3 minutes. The left stent exchange was via an ileal conduit.

3. Left retrograde pyelogram.

4. Vaginoscopy with pelvic exam under anesthesia.

INDICATION: This woman is five months status post radical cystectomy with indwelling left ureteral stent, hydronephrosis, vaginal discharge, and presents at this time for evaluation.

FINDINGS: Upon looposcopy, in the butt of the conduit, there was a single vascular staple that I removed with a grasping instrument.

Next, the 7-French stent exchange was carried out under fluoroscopic guidance. Retrograde pyelogram demonstrated the proximal curl in the renal pelvis. Vaginal examination revealed no pelvic mass on bimanual examination, and vaginoscopy with a flexible scope showed no vaginal lesions implying that she has normal postoperative vaginal discharge. She tolerated the procedure well.

Florida Subscriber

Answer: First, report 52310 (Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder [separate procedure]; simple) for the removal of the foreign body, as the ileal conduit represents a substitute bladder. Attach modifier 52 (Reduced services) since your urologist did not perform a cystoscopy.

Next, report 44380 (Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) for the looposcopy, which took the place of the cystoscopy.

Then, report 50688 (Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit) for the change of the stent via an ileal conduit.

Finally, report 57420 (Colposcopy of the entire vagina, with cervix if present) for the vaginoscopy.