toria11
Guru
Hi all, any help with this OP note is appreciated. One of my coders used: 50590, 52318, and 52315-XU. 52315 was denied, of course. I'm thinking 52356 would have been more appropriate here since the stent was initially placed during this encounter and you can't bill for removing a stent you've just placed, but 52356 just causes even more bundling issues. Thoughts?
A rigid cystoscope was carefully passed down his penis into his bladder without any difficulty.
Once inside the bladder, I was able to locate the stent where
he had a large stone approximately 2 cm associated with the distal portion of the stent. A 550 micron
laser fiber was used to completely fragment the stone off of the distal portion of the stent until the stent
could be visualized. I then used Ellik evacuator and removed the fragments from the bladder. This will be
sent off for chemical analysis of his bladder calculi. At this time, I reinserted the rigid cystoscope. I used
a flexible grasper and under guidance of fluoroscopy, I attempted to remove the stent but the proximal
portion would not uncurl and met significant resistance. Therefore, I removed the stent and I was able to
pass a guidewire up the left ureter into the left kidney under guidance of fluoroscopy. I used a semirigid
ureteroscope to go alongside the wire and went up in the left ureter. The stent in the ureter itself was free
of any calcifications. However, as I got close to the UPJ and I could in the distance see the proximal
portion of the retained stent with a large stone associated with it, but I could not have reach it with the
rigid ureteroscope. Therefore, I passed a second wire through the rigid ureteroscope into the left kidney
and removed the rigid ureteroscope leaving two wires and the indwelling stent in place. I attempted to
pass a flexible ureteroscope over the wire up into his left ureter, but was meeting significant resistance at
the ureteral orifice. Therefore, with help of fluoroscopy, I used ureteral access sheath and gently passed
over one of the guidewires up into the mid ureter. This was done over fluoroscopy. The sheath and wire
were removed leaving the access sheath in place. I then advanced the flexible ureteroscope through the
inner sheath up into the left kidney. I was able to come across the proximal curl in the kidney, but
visualization was quite poor due to mild debris and blood in his kidney. I used a 200 micron laser fiber to
attempt the fragment some of the stone off of the proximal portion of the stent. However, visualization
became quite difficult during the lithotripsy of this ureteral stent. Therefore, I then removed the flexible
ureteroscope. I replaced a guidewire through the access sheath up into the left kidney and removed the
access sheath. So, once again there were two wires and the retained stent in place. I reinserted the rigid
cystoscope and grabbed the distal portion of the stent and attempted to remove it but once again it did not
uncurl under fluoroscopy. At this time, with one of the wires in place, I backloaded a 6-French x 24 cm
stent over the wire up into the left kidney into the upper pole. This was confirmed by fluoroscopy. The
wire was removed and stent appeared to be in proper position. The distal portion of the stent with the
wire attached to it was secured to his penis with Steri-Strips. At this point, he was remained intubated.
He was transferred next door to the other operating room where a left ESWL was performed.
Approximately, 1500 shocks at an intensity level of 5 were then given to his proximal curl of the left
ureteral stent. After 1500 shocks were given, I passed a flexible cystoscope down his penis into his
bladder. Both stents were visualized. I grabbed the retained stent with calcifications on it and gently
pulled it out under guidance of fluoroscopy. It did uncurl and come out but as coming out, it pulled out the
new stent as well and both stents were subsequently removed. At this point, I decided since he had an
indwelling stent for over four months and was lost a follow up, I did not replace the stent. This concluded the procedure.
A rigid cystoscope was carefully passed down his penis into his bladder without any difficulty.
Once inside the bladder, I was able to locate the stent where
he had a large stone approximately 2 cm associated with the distal portion of the stent. A 550 micron
laser fiber was used to completely fragment the stone off of the distal portion of the stent until the stent
could be visualized. I then used Ellik evacuator and removed the fragments from the bladder. This will be
sent off for chemical analysis of his bladder calculi. At this time, I reinserted the rigid cystoscope. I used
a flexible grasper and under guidance of fluoroscopy, I attempted to remove the stent but the proximal
portion would not uncurl and met significant resistance. Therefore, I removed the stent and I was able to
pass a guidewire up the left ureter into the left kidney under guidance of fluoroscopy. I used a semirigid
ureteroscope to go alongside the wire and went up in the left ureter. The stent in the ureter itself was free
of any calcifications. However, as I got close to the UPJ and I could in the distance see the proximal
portion of the retained stent with a large stone associated with it, but I could not have reach it with the
rigid ureteroscope. Therefore, I passed a second wire through the rigid ureteroscope into the left kidney
and removed the rigid ureteroscope leaving two wires and the indwelling stent in place. I attempted to
pass a flexible ureteroscope over the wire up into his left ureter, but was meeting significant resistance at
the ureteral orifice. Therefore, with help of fluoroscopy, I used ureteral access sheath and gently passed
over one of the guidewires up into the mid ureter. This was done over fluoroscopy. The sheath and wire
were removed leaving the access sheath in place. I then advanced the flexible ureteroscope through the
inner sheath up into the left kidney. I was able to come across the proximal curl in the kidney, but
visualization was quite poor due to mild debris and blood in his kidney. I used a 200 micron laser fiber to
attempt the fragment some of the stone off of the proximal portion of the stent. However, visualization
became quite difficult during the lithotripsy of this ureteral stent. Therefore, I then removed the flexible
ureteroscope. I replaced a guidewire through the access sheath up into the left kidney and removed the
access sheath. So, once again there were two wires and the retained stent in place. I reinserted the rigid
cystoscope and grabbed the distal portion of the stent and attempted to remove it but once again it did not
uncurl under fluoroscopy. At this time, with one of the wires in place, I backloaded a 6-French x 24 cm
stent over the wire up into the left kidney into the upper pole. This was confirmed by fluoroscopy. The
wire was removed and stent appeared to be in proper position. The distal portion of the stent with the
wire attached to it was secured to his penis with Steri-Strips. At this point, he was remained intubated.
He was transferred next door to the other operating room where a left ESWL was performed.
Approximately, 1500 shocks at an intensity level of 5 were then given to his proximal curl of the left
ureteral stent. After 1500 shocks were given, I passed a flexible cystoscope down his penis into his
bladder. Both stents were visualized. I grabbed the retained stent with calcifications on it and gently
pulled it out under guidance of fluoroscopy. It did uncurl and come out but as coming out, it pulled out the
new stent as well and both stents were subsequently removed. At this point, I decided since he had an
indwelling stent for over four months and was lost a follow up, I did not replace the stent. This concluded the procedure.