ksrkelly7
Networker
Hi there,
I am new to Urology coding and would like some help with this OP report please. I know there are new codes for 2016 as well. Any help with this would be greatly appreciated.
Indication for Surgery 2 large left renal stones
Preoperative Diagnosis Same
Postoperative Diagnosis Same
Operation Cystoscopy, left ureteroscopy with laser lithotripsy Percutaneous nephrostomy tube and left percutaneous nephrolithotomy with placement of nephroureteral stents
Findings No evidence of residual stone fragments by nephroscopy, ureteroscopy or fluoroscopy
Specimen(s) Stone fragments
Complications None
Technique After satisfactory timeout the patient underwent induction of general anesthesia in the supine position and then was placed in the prone position and a superman type position with leg spreaders in place. The patient had a pre-existing left double-J stent. The patient was prepped and draped in the genitalia region and also the left back. Cystoscopy was carried out and the existing double-J stent was brought to the meatus but due to encrustation a guidewire could not be placed through the stent. The stent was eventually removed and with some difficulty related to mucosal edema and a 0.035 sensor wire was placed in the region of the left renal pelvis. An 8/10 dilator was then placed and a second wire placed similarly. A 12/14 ureteral access sheath was placed to about the level of just below the stone. Flexible ureteroscopy was then undertaken but we were unable to manipulate the ureteroscope past the stone to allow the tip of the ureteroscope to be used as a "bull's-eye" for placement of the nephrostomy tract. Because of this a laser was introduced and the stone was partially treated with laser to allow passage of the scope on the medial side of the stone up to the level of the superior pole of the kidney above the very large stone. Various fluoroscopic images were captured throughout this entire process and safe to the PACS unit. The ureteroscope was maneuvered up to a superior lateral calyx which was chosen to have of time as the target. Contrast was utilized through the ureteroscope to make sure this was in the correct position. Various anatomic landmarks were marked with the use of fluoroscope including the ribs and the stone location. Utilizing fluoroscopy and the patient at end expiration an appropriate spot was chosen overlying the tip of the ureteroscope and a trocar needle was passed with a bull's-eye technique with only 1 correction needed to be made until the trocar needle was seen to enter the calyx exactly where we chose it to enter. A 0.035 sensor wire was then placed through the trocar and under vision was brought through the ureteral sheath and used as a through and through safety wire. I used the fascial dilator after the skin had been incised over the existing wire in the flank. The 8/10 ureteral catheter was placed over the existing wire and a second wire was placed. The ureteral access sheath was then removed and reintroduced over one of the wires so that the other wire was outside the sheath to allow room for the ureteroscope. Both ends of that wire were clamped as a through and through wire. After fascial dilatation was completed I passed the ureteral balloon dilating catheter which was again observed entering the kidney under direct vision from the ureteroscope and inflated in a typical fashion to about 7 atm to allow dilatation of the tract. The nephroscope sheath was then placed over the balloon a typical fashion and the balloon removed. The nephroscope was then introduced some clots were removed and the stone was fragmented. Fragments were removed with the Perk-n- Circle device. After sequential fragmentation of the stone with removal of all visible pieces the calyces were inspected from below as well as from above. From below the flexible ureteroscope was used and from above the flexible cystoscope as well as the nephroscope were used and no significant stone fragments were noted. The patient then had the sheath withdrawn and there was no evidence of unusual bleeding from the nephrostomy tract and a nephroureteral stent placed with the use of fluoroscopy and cystoscopy. Nephroureteral stent positioning in both the kidney and bladder were accomplished using fluoroscopy and cystoscopy respectively. Silk sutures were placed over the nephrostomy incision and the nephrostomy tube was secured to the skin and placed to gravity drainage. The patient had some bleeding per bladder and so a larger Foley catheter was placed and may be placed to bladder irrigation once he is evaluated in the recovery room. The patient was awake and transferred to the stretcher and taken the recovery room in stable condition.
Thanks so much!!
Kelly, CPC
I am new to Urology coding and would like some help with this OP report please. I know there are new codes for 2016 as well. Any help with this would be greatly appreciated.
Indication for Surgery 2 large left renal stones
Preoperative Diagnosis Same
Postoperative Diagnosis Same
Operation Cystoscopy, left ureteroscopy with laser lithotripsy Percutaneous nephrostomy tube and left percutaneous nephrolithotomy with placement of nephroureteral stents
Findings No evidence of residual stone fragments by nephroscopy, ureteroscopy or fluoroscopy
Specimen(s) Stone fragments
Complications None
Technique After satisfactory timeout the patient underwent induction of general anesthesia in the supine position and then was placed in the prone position and a superman type position with leg spreaders in place. The patient had a pre-existing left double-J stent. The patient was prepped and draped in the genitalia region and also the left back. Cystoscopy was carried out and the existing double-J stent was brought to the meatus but due to encrustation a guidewire could not be placed through the stent. The stent was eventually removed and with some difficulty related to mucosal edema and a 0.035 sensor wire was placed in the region of the left renal pelvis. An 8/10 dilator was then placed and a second wire placed similarly. A 12/14 ureteral access sheath was placed to about the level of just below the stone. Flexible ureteroscopy was then undertaken but we were unable to manipulate the ureteroscope past the stone to allow the tip of the ureteroscope to be used as a "bull's-eye" for placement of the nephrostomy tract. Because of this a laser was introduced and the stone was partially treated with laser to allow passage of the scope on the medial side of the stone up to the level of the superior pole of the kidney above the very large stone. Various fluoroscopic images were captured throughout this entire process and safe to the PACS unit. The ureteroscope was maneuvered up to a superior lateral calyx which was chosen to have of time as the target. Contrast was utilized through the ureteroscope to make sure this was in the correct position. Various anatomic landmarks were marked with the use of fluoroscope including the ribs and the stone location. Utilizing fluoroscopy and the patient at end expiration an appropriate spot was chosen overlying the tip of the ureteroscope and a trocar needle was passed with a bull's-eye technique with only 1 correction needed to be made until the trocar needle was seen to enter the calyx exactly where we chose it to enter. A 0.035 sensor wire was then placed through the trocar and under vision was brought through the ureteral sheath and used as a through and through safety wire. I used the fascial dilator after the skin had been incised over the existing wire in the flank. The 8/10 ureteral catheter was placed over the existing wire and a second wire was placed. The ureteral access sheath was then removed and reintroduced over one of the wires so that the other wire was outside the sheath to allow room for the ureteroscope. Both ends of that wire were clamped as a through and through wire. After fascial dilatation was completed I passed the ureteral balloon dilating catheter which was again observed entering the kidney under direct vision from the ureteroscope and inflated in a typical fashion to about 7 atm to allow dilatation of the tract. The nephroscope sheath was then placed over the balloon a typical fashion and the balloon removed. The nephroscope was then introduced some clots were removed and the stone was fragmented. Fragments were removed with the Perk-n- Circle device. After sequential fragmentation of the stone with removal of all visible pieces the calyces were inspected from below as well as from above. From below the flexible ureteroscope was used and from above the flexible cystoscope as well as the nephroscope were used and no significant stone fragments were noted. The patient then had the sheath withdrawn and there was no evidence of unusual bleeding from the nephrostomy tract and a nephroureteral stent placed with the use of fluoroscopy and cystoscopy. Nephroureteral stent positioning in both the kidney and bladder were accomplished using fluoroscopy and cystoscopy respectively. Silk sutures were placed over the nephrostomy incision and the nephrostomy tube was secured to the skin and placed to gravity drainage. The patient had some bleeding per bladder and so a larger Foley catheter was placed and may be placed to bladder irrigation once he is evaluated in the recovery room. The patient was awake and transferred to the stretcher and taken the recovery room in stable condition.
Thanks so much!!
Kelly, CPC