Hi, this patient underwent an open cystolithotomy (51050) and I'm wondering if I need to bill separately for the ureteral stent removal that was performed during the procedure? The note states the stent was delivered out of the bladder through the incision and I'm not sure how I would code that. Thanks!
POSTOPERATIVE DIAGNOSIS:
1. Retained left ureteral stent with large cyst urethral stone and renal stone.
2. History of myelomeningocele with neurogenic bladder.
PROCEDURE PERFORMED: Cystolithotomy.
SPECIMENS REMOVED:
Cysto urethral stone and distal ureteral stent.
INDICATIONS:
The patient is a female who has a small medium stone in the renal pelvis on the left-hand side and an extremely large cystic urethral stone measuring up to 6 cm. She presents for definitive treatment of her bladder stone. She had a left nephrostomy tube placed and has had minimal output indicating a poorly-functioning left kidney.
FINDINGS:
Her 6 cm stone was able to be delivered through a cystotomy incision. The distal stent was transected and noted to be free of stones.
DETAILS OF PROCEDURE:
The patient was taken to the operating room and positively identified as well as the site of surgery during a time-out. After adequate general anesthesia, she was left in the supine position. She has severe flexion contractures with her hips in a fully abducted position at rest. She has very small stature and severe scoliosis from her history of myelomeningocele. Her indwelling Foley catheter was removed. Her large cystic urethral stone was palpated and noted to extend all way down to the urethral meatus. Therefore, cystolitholapaxy was not deemed safe. She was then prepped and draped in the usual sterile fashion for cystolithotomy. Local anesthetic was injected in the midline prior to incision. A 15 blade scalpel knife was then used to make an incision from the pubic symphysis to midway to the umbilicus. Electrocautery was then used to dissect down to the linea alba, which was divided down to the pubic symphysis. I was able to bluntly dissect underneath the rectus abdominis and extend the fascial incision without entering the peritoneal cavity. I was unable to place Foley catheter successfully due to her obstructing urethral stone. I was able to dissect down to the bladder and developed the space of Retzius and identified the bladder with a 22-gauge needle used to fill and aspirate the bladder. Two 3-0 Vicryl stay stitches were placed in the bladder. The bladder was opened between the stay stitches with electrocautery. The incision was enlarged and a Richardson retractor placed in the dome with the Ray-Tec to provide exposure. The stone was able to be delivered with manual pressure intravaginally. The stone was delivered up into the cystotomy. Once it was delivered out of the bladder, the stent was identified and noted to be free of calcifications. It was transected near the level of the left ureteral orifice. Bladder was then irrigated with copious amounts of saline. The bladder was closed in layers with a 4-0 and 3-0 running Vicryl suture. The bladder was then irrigated and there was efflux around the catheter, but no evidence of leaking from the bladder closure. Wound was then irrigated again with copious amounts of saline. The fascia was closed with a running 2-0 Vicryl stitch. Subcutaneous tissue was irrigated and reapproximated with interrupted 2-0 and 3-0 Vicryl. The skin was closed with a running subcuticular 4-0 Monocryl. Steri-Strips and a sterile dressing were applied. At the end of the procedure. All counts were correct. A 16-French Foley catheter was left in the bladder. The balloon was inflated to 10 mL after the bladder was closed. The catheter was left to gravity drainage. Hemostasis was excellent. Urine culture was obtained intraoperatively with direct bladder aspiration. 20220606 SR
POSTOPERATIVE DIAGNOSIS:
1. Retained left ureteral stent with large cyst urethral stone and renal stone.
2. History of myelomeningocele with neurogenic bladder.
PROCEDURE PERFORMED: Cystolithotomy.
SPECIMENS REMOVED:
Cysto urethral stone and distal ureteral stent.
INDICATIONS:
The patient is a female who has a small medium stone in the renal pelvis on the left-hand side and an extremely large cystic urethral stone measuring up to 6 cm. She presents for definitive treatment of her bladder stone. She had a left nephrostomy tube placed and has had minimal output indicating a poorly-functioning left kidney.
FINDINGS:
Her 6 cm stone was able to be delivered through a cystotomy incision. The distal stent was transected and noted to be free of stones.
DETAILS OF PROCEDURE:
The patient was taken to the operating room and positively identified as well as the site of surgery during a time-out. After adequate general anesthesia, she was left in the supine position. She has severe flexion contractures with her hips in a fully abducted position at rest. She has very small stature and severe scoliosis from her history of myelomeningocele. Her indwelling Foley catheter was removed. Her large cystic urethral stone was palpated and noted to extend all way down to the urethral meatus. Therefore, cystolitholapaxy was not deemed safe. She was then prepped and draped in the usual sterile fashion for cystolithotomy. Local anesthetic was injected in the midline prior to incision. A 15 blade scalpel knife was then used to make an incision from the pubic symphysis to midway to the umbilicus. Electrocautery was then used to dissect down to the linea alba, which was divided down to the pubic symphysis. I was able to bluntly dissect underneath the rectus abdominis and extend the fascial incision without entering the peritoneal cavity. I was unable to place Foley catheter successfully due to her obstructing urethral stone. I was able to dissect down to the bladder and developed the space of Retzius and identified the bladder with a 22-gauge needle used to fill and aspirate the bladder. Two 3-0 Vicryl stay stitches were placed in the bladder. The bladder was opened between the stay stitches with electrocautery. The incision was enlarged and a Richardson retractor placed in the dome with the Ray-Tec to provide exposure. The stone was able to be delivered with manual pressure intravaginally. The stone was delivered up into the cystotomy. Once it was delivered out of the bladder, the stent was identified and noted to be free of calcifications. It was transected near the level of the left ureteral orifice. Bladder was then irrigated with copious amounts of saline. The bladder was closed in layers with a 4-0 and 3-0 running Vicryl suture. The bladder was then irrigated and there was efflux around the catheter, but no evidence of leaking from the bladder closure. Wound was then irrigated again with copious amounts of saline. The fascia was closed with a running 2-0 Vicryl stitch. Subcutaneous tissue was irrigated and reapproximated with interrupted 2-0 and 3-0 Vicryl. The skin was closed with a running subcuticular 4-0 Monocryl. Steri-Strips and a sterile dressing were applied. At the end of the procedure. All counts were correct. A 16-French Foley catheter was left in the bladder. The balloon was inflated to 10 mL after the bladder was closed. The catheter was left to gravity drainage. Hemostasis was excellent. Urine culture was obtained intraoperatively with direct bladder aspiration. 20220606 SR