richmorris10
Guest
Please help! Trying to obtain the correct CPT for the below procedure can anyone please help me!!
Procedure/findings:
The procedure, risks, benefits, and alternatives were discussed with the
patient, and signed informed consent was obtained. The patient was placed prone
on the angiographic procedure table, and the left flank was prepped and draped
in sterile fashion. Maximum sterile barrier technique was utilized. A timeout
was performed verifying patient and the procedure.
Ultrasound was used to identify the left kidney. 1% lidocaine was injected into
the skin and deeper soft tissues overlying a posterior calyx. A dermatotomy was
made with 11 blade. A 21-gauge needle was advanced into a posterior calyx
containing a stone under direct sonographic guidance. An ultrasound image was
saved and sent to PACS. The stylet was removed, and contrast injection confirmed
appropriate entry into the collecting system, after multiple attempts. The
needle was exchanged over a 0.018 wire for a 6 French transitional dilator. The
stiffener and wire were removed, and the sheath was then exchanged over a 0.035
wire for an 5 French Kumpe catheter. The catheter and wire were manipulated down
the ureter into the urinary bladder. Catheter was exchanged for a 6 French
vascular sheath, and a second wire was advanced through the sheath into the
urinary bladder. The sheath was removed, and a Kumpe catheter was advanced over
each wire, leaving the tips of the wires in the urinary bladder. The catheters
were secured with a sterile dressing. The patient tolerated the procedure well,
and there were no complications.
Fluoroscopy time: 28.6 min
Fluoroscopy images: 4
Moderate sedation: Versed and fentanyl IV was administered. Rocephin 1 g IV.
Continuous nursing monitoring was performed throughout the procedure for a total
of 97 minutes under the direct supervision of Dr. McElmurray.
Complications: None
Impression:
Successful ultrasound and fluoroscopic guided left PCN placement x2 for right
PCNL scheduled later today.
Procedure/findings:
The procedure, risks, benefits, and alternatives were discussed with the
patient, and signed informed consent was obtained. The patient was placed prone
on the angiographic procedure table, and the left flank was prepped and draped
in sterile fashion. Maximum sterile barrier technique was utilized. A timeout
was performed verifying patient and the procedure.
Ultrasound was used to identify the left kidney. 1% lidocaine was injected into
the skin and deeper soft tissues overlying a posterior calyx. A dermatotomy was
made with 11 blade. A 21-gauge needle was advanced into a posterior calyx
containing a stone under direct sonographic guidance. An ultrasound image was
saved and sent to PACS. The stylet was removed, and contrast injection confirmed
appropriate entry into the collecting system, after multiple attempts. The
needle was exchanged over a 0.018 wire for a 6 French transitional dilator. The
stiffener and wire were removed, and the sheath was then exchanged over a 0.035
wire for an 5 French Kumpe catheter. The catheter and wire were manipulated down
the ureter into the urinary bladder. Catheter was exchanged for a 6 French
vascular sheath, and a second wire was advanced through the sheath into the
urinary bladder. The sheath was removed, and a Kumpe catheter was advanced over
each wire, leaving the tips of the wires in the urinary bladder. The catheters
were secured with a sterile dressing. The patient tolerated the procedure well,
and there were no complications.
Fluoroscopy time: 28.6 min
Fluoroscopy images: 4
Moderate sedation: Versed and fentanyl IV was administered. Rocephin 1 g IV.
Continuous nursing monitoring was performed throughout the procedure for a total
of 97 minutes under the direct supervision of Dr. McElmurray.
Complications: None
Impression:
Successful ultrasound and fluoroscopic guided left PCN placement x2 for right
PCNL scheduled later today.