Bernadette10
Guru
This patient was seen in outpatient surgery for a previously scheduled surgery for a stent removal. During the consent process he decided he didn't want to have the procedure. Can an E/M charge be billed for this?
Summary: Pt refuses procedure
53-year-old male who presents today for right ureteral stent removal with exchange.
During the consultation and consent procedure the patient was informed that his stent had been in for 9 months since the implantation and that it is encrusted certainly on the bladder side and most likely on the proximal end as well. We discussed the realistic possibility of this 4.7 French ureteral stent fracturing during the removal portion of this procedure, and if this were to happen that a percutaneous nephrostomy may well need to be performed. The patient was not willing to accept this potential risk and as such refuses to undergo the procedure today. I have advised him that he absolutely needs to have the stent removed and replaced at some point. We did discuss the possibility of using shockwave lithotripsy to fracture any possible proximal encrustation of the proximal coil, and the patient was willing to discuss this at is an alternative but understands that he still needs to have the stent removed and replaced or continue to carry the risk of stent fracturing.
The patient is well aware of the risks that have developed having had the stent in place for an additional 6 months beyond the original stent replacement date. The patient is well aware of this.
He will follow-up either my office or Dr. X's office and further plans will be made.
Summary: Pt refuses procedure
53-year-old male who presents today for right ureteral stent removal with exchange.
During the consultation and consent procedure the patient was informed that his stent had been in for 9 months since the implantation and that it is encrusted certainly on the bladder side and most likely on the proximal end as well. We discussed the realistic possibility of this 4.7 French ureteral stent fracturing during the removal portion of this procedure, and if this were to happen that a percutaneous nephrostomy may well need to be performed. The patient was not willing to accept this potential risk and as such refuses to undergo the procedure today. I have advised him that he absolutely needs to have the stent removed and replaced at some point. We did discuss the possibility of using shockwave lithotripsy to fracture any possible proximal encrustation of the proximal coil, and the patient was willing to discuss this at is an alternative but understands that he still needs to have the stent removed and replaced or continue to carry the risk of stent fracturing.
The patient is well aware of the risks that have developed having had the stent in place for an additional 6 months beyond the original stent replacement date. The patient is well aware of this.
He will follow-up either my office or Dr. X's office and further plans will be made.
