sammartin92472
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Please help with this one. I work coding denials for multispecialty practice and need some help with urology. This is a pediatric patient. This procedure was for closure of a vesicostomy and left ureteral implantation. The initial coder coded this procedure with 50780 and 51880-51 and the 51880-51 was denied as incidental. 51880 is a "separate procedure", so I know it either gets billed alone or with a 59 mod if reported with an unrelated procedure. My question is basically is the 50780 truly an unrelated procedure from the 51880 or should the 50780 encompass the whole procedure. There is no CCI edit between the two. Here's the note:
PREOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.
POSTOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.
PROCEDURE:
1. Closure of vesicostomy
2. Left ureteral reimplantation.
INDICATIONS:
Patient is a 13-year-old boy with low level myelomeningocele with resulting bowel and bladder dysfunction. He has been managed with vesicostomy due to his unwillingness to perform intermittent catheterization. He is now performing intermittent cath and would like closure of the vesicostomy. There is also grade 4 left reflux which persists despite previous Deflux injection.
FINDINGS:
Vesicostomy with evidence of chronic bladder inflammation. Deflux injection sites noted around left orifice with significant fibrosis.
DESCRIPTION OF PROCEDURE:
After adequate general anesthesia was obtained, the patient was placed in a supine position and the external genitalia and lower abdomen were prepped and draped in usual sterile fashion. A 12-French Foley catheter was inserted in the vesicostomy site and the balloon inflated. A transverse incision was then made encompassing the vesicostomy site and carried down to the rectus fascia. This was opened transversely and elevated in the fashion of a Pfannenstiel incision. The vesicostomy site was secured with 2 sutures of 3-0 silk and dissected free from the rectus muscles. The bladder was then opened in the midline. The mucosa was noted to be mildly inflamed throughout. The Bookwalter retractor was then brought onto the field and placed in such a manner as to allow adequate visualization of the bladder interior. Despite this, however, there was exceptional difficulty seeing the area of the trigone due to superior location of the vesicostomy incision. For this reason the rectus fascia was then divided in the midline inferiorly to allow further separation of the muscle and better visualization of the base of the bladder. The left ureteral orifice was identified and cannulated with a 5-French feeding tube without difficulty. The right ureteral orifice was also identified. Dissection was then performed to free the left ureter from the surrounding detrusor. There was exceptional fibrotic reaction, however, and this intravesical dissection was unsuccessful. The ureter was entered during the dissection and I made the decision to perform extravesical dissection. The Bookwalter was rearranged to allow visualization of the left perivesical space. Dissection was commenced and it was noted that there was a very large amount of hard stool throughout the colon. This filled the pelvis and made dissection more difficult. The left vas deferens was identified and protected. Because of the difficulty in dissection I asked Dr. Chandler, pediatric surgeon, to come in and assist. We were then able to free the ureter from the surrounding detrusor muscle up to the pelvic brim. During this dissection the Deflux mounds were encountered and removed. Adequate length was then gained for ureteral reimplantation. The ureter was brought in through the posterior aspect of the bladder and a submucosal tunnel created in a Politano-Leadbetter fashion. The ureter was secured in its new location with interrupted 4-0 Vicryl suture. The defect where the left ureter was originally located was significant due to the degree of fibrosis. This was closed with running 2-0 Vicryl suture. The bladder was then closed with 2 layers, the first layer of 2-0 Vicryl followed by a second layer of 3-0 Vicryl. Prior to this, clear efflux was seen from both the right and left ureteral orifices. An 18-French Foley catheter was then brought out through the right side of the abdomen and secured with 3-0 nylon suture. The rectus fascia was closed with running 2-0 Vicryl. The wound then closed in layers with 3-0 and 5-0 Vicryl. A 12-French Foley catheter was inserted per urethra with return of light pink urine. Irrigation of suprapubic catheter showed no significant bladder leak prior to closure of the fascia. The wound was infiltrated with 0.25% Sensorcaine and sterile dressing applied. The patient was awakened and transferred to the recovery room.
Thanks in advance for you help!
PREOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.
POSTOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.
PROCEDURE:
1. Closure of vesicostomy
2. Left ureteral reimplantation.
INDICATIONS:
Patient is a 13-year-old boy with low level myelomeningocele with resulting bowel and bladder dysfunction. He has been managed with vesicostomy due to his unwillingness to perform intermittent catheterization. He is now performing intermittent cath and would like closure of the vesicostomy. There is also grade 4 left reflux which persists despite previous Deflux injection.
FINDINGS:
Vesicostomy with evidence of chronic bladder inflammation. Deflux injection sites noted around left orifice with significant fibrosis.
DESCRIPTION OF PROCEDURE:
After adequate general anesthesia was obtained, the patient was placed in a supine position and the external genitalia and lower abdomen were prepped and draped in usual sterile fashion. A 12-French Foley catheter was inserted in the vesicostomy site and the balloon inflated. A transverse incision was then made encompassing the vesicostomy site and carried down to the rectus fascia. This was opened transversely and elevated in the fashion of a Pfannenstiel incision. The vesicostomy site was secured with 2 sutures of 3-0 silk and dissected free from the rectus muscles. The bladder was then opened in the midline. The mucosa was noted to be mildly inflamed throughout. The Bookwalter retractor was then brought onto the field and placed in such a manner as to allow adequate visualization of the bladder interior. Despite this, however, there was exceptional difficulty seeing the area of the trigone due to superior location of the vesicostomy incision. For this reason the rectus fascia was then divided in the midline inferiorly to allow further separation of the muscle and better visualization of the base of the bladder. The left ureteral orifice was identified and cannulated with a 5-French feeding tube without difficulty. The right ureteral orifice was also identified. Dissection was then performed to free the left ureter from the surrounding detrusor. There was exceptional fibrotic reaction, however, and this intravesical dissection was unsuccessful. The ureter was entered during the dissection and I made the decision to perform extravesical dissection. The Bookwalter was rearranged to allow visualization of the left perivesical space. Dissection was commenced and it was noted that there was a very large amount of hard stool throughout the colon. This filled the pelvis and made dissection more difficult. The left vas deferens was identified and protected. Because of the difficulty in dissection I asked Dr. Chandler, pediatric surgeon, to come in and assist. We were then able to free the ureter from the surrounding detrusor muscle up to the pelvic brim. During this dissection the Deflux mounds were encountered and removed. Adequate length was then gained for ureteral reimplantation. The ureter was brought in through the posterior aspect of the bladder and a submucosal tunnel created in a Politano-Leadbetter fashion. The ureter was secured in its new location with interrupted 4-0 Vicryl suture. The defect where the left ureter was originally located was significant due to the degree of fibrosis. This was closed with running 2-0 Vicryl suture. The bladder was then closed with 2 layers, the first layer of 2-0 Vicryl followed by a second layer of 3-0 Vicryl. Prior to this, clear efflux was seen from both the right and left ureteral orifices. An 18-French Foley catheter was then brought out through the right side of the abdomen and secured with 3-0 nylon suture. The rectus fascia was closed with running 2-0 Vicryl. The wound then closed in layers with 3-0 and 5-0 Vicryl. A 12-French Foley catheter was inserted per urethra with return of light pink urine. Irrigation of suprapubic catheter showed no significant bladder leak prior to closure of the fascia. The wound was infiltrated with 0.25% Sensorcaine and sterile dressing applied. The patient was awakened and transferred to the recovery room.
Thanks in advance for you help!