Wiki Extraction of stone from left ureteral orifice with grasper.

[carol52]

Hello I'm not exactly sure what was performed on the surgery.
The op note states on the left side:
Attention was turned to the left stone, which could be seen at the ureteral orifice. A grasper was used.
The stone was crushed and it was extracted.
A double J stent was inserted.
Did Dr. use a basket what is meant by grasper and how was the stone crushed ... I'm assuming laser....
any feedback would help
Thanks,
Carol

 

[thomas7331]

A grasper would be a mechanical tool such as forceps, probably one that was threaded through the cystoscope or ureteroscope.

I could not tell you if a laser or basket was used or not, but I would definitely not assume either unless it is specifically stated. (Lasers are not always used, and laser procedures are reimbursed at a higher rate, so I would not code that unless it was documented.) If your report is ambiguous, though, or contains conflicting information that prevent you from arriving at an accurate code, then you'll need to query your provider.

 

[liqgold2@aol.com]

A very good question and a very good answer. I would consider a stone at the ureteral meatus a ureteral stone. I would suggest code 52325 with fragmentation and stone removal as the coding choice.
From Michael A. Ferragamo MD, FACS, urologist and urology coding and reimbursement consultant