I am new to Urology field and having issues with a PCNL - Previous manager coded this report and doc thinks all PCNL's should be coded the same - Please let me know what you think? I know its' long - but your help is very much appreciated. Thanks in Advance
CPT CODES BILLED FOR THIS OP REPORT:
50081 - PCNL for stones >2.0 cm
52352 - Cystoscopy basket extraction of stones
50393 -Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous
52332 - Stent insertion
50394 - Injection procedure for pyelography (as nephrostogram, pyelostogram, antegrade pyeloureterograms) through nephrostomy or pyelostomy tube, or indwelling ureteral catheter
Op Report:
POSTOPERATIVE DIAGNOSIS: Right staghorn calculus.
OPERATION PERFORMED: Right percutaneous nephrolithotomy, right antegrade pyelogram, right renoscopy and proximal ureteroscopy, placement of 6 x 22 right ureteral stent in an antegrade fashion, placement of 22-French Councill tip catheter and nephrostomy tube.
DRAINS: A 6 x 22 double-J ureteral stent, a 22-French Councill tip catheter, 16-French Foley catheter.
INDICATIONS FOR PROCEDURE: 65-year-old female with a history of right staghorn calculus. She became septic placement of nephroureteral stent. However, she has improved, and she presents for surgical intervention today.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient. She was then taken back to the Operative Suite and anesthesia was induced without incident. She was placed in the prone position, taking care to pad all pressure points. She was given perioperative antibiotics. She was then prepped and draped in the sterile fashion. At this point in time, a scout fluoroscopy was taken showing nephroureteral stent in place and the staghorn calculus also noted. It was very opaque. A ephrostogram was showing moderate hydroureteronephrosis. An Amplatz Super Stiff Guidewire was advanced into the nephroureteral stent down to the bladder under fluoroscopic vision and the nephroureteral stent removed. A dual-lumen access sheath was inserted, and a second Amplatz Super Stiff Guidewire was inserted. A #15 blade scalpel was used to incise the entry of the nephrostomy tube site to allow access to the dilator. A 30-French NephroMax balloon dilator was then advanced with the proximal tip in the renal pelvis. The balloon was dilated [1 to 14 mmHg under fluoroscopic vision until fascial waist was adequately dilated. The access sheath was slid over the balloon liner into the proximal renal pelvis, and the balloon was removed. The nephroscope was inserted, and the stone was immediately visualized. The stone was removed using a combination of ultrasonic lithotripsy. All the fragments were irrigated out. There was a residual stone fragment in the right lower pole I was unable to access with the nephroscope, and thus the nephroscope was exchanged for a flexible cystoscope, and a renoscopy and proximal ureteroscopy was performed showing no fragments. The scope was inserted into the right lower pole and using the 2651 micron holmium laser fiber, the stone was ablated into multiple smaller fragments. These were removed using a combination of basket extraction and percutaneous ultrasonic lithotripsy. A repeat renoscopy did not show any evidence of calculi, and bleeding was minimal. There was no extravasation of urine from the renal pelvis by nephrostogram.
Once I was satisfied that I had removed the patient's stone burden, the cystoscope was removed and a 6 x 22 double-J ureteral stent was inserted into the right ureteral system. Good curl in renal pulse pelvis and the bladder. This was done under direct and fluoroscopic vision. The wire was removed, leaving one final Amplatz guidewire on which a 22-French Councill tip catheter was advanced over with the tip in the renal pelvis. The balloon was inflated to 3 cc. Nephrostogram showed no extravasation of urine. Once I was satisfied with the placement, all wires and the access sheath were removed. The Councill tip catheter acting as nephrostomy tube was secured to the patient's flank with 2-0 silk suture. The wound was then dressed with ABD pads The patient was returned to the Post Anesthesia Care Unit in stable condition.
CPT CODES BILLED FOR THIS OP REPORT:
50081 - PCNL for stones >2.0 cm
52352 - Cystoscopy basket extraction of stones
50393 -Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous
52332 - Stent insertion
50394 - Injection procedure for pyelography (as nephrostogram, pyelostogram, antegrade pyeloureterograms) through nephrostomy or pyelostomy tube, or indwelling ureteral catheter
Op Report:
POSTOPERATIVE DIAGNOSIS: Right staghorn calculus.
OPERATION PERFORMED: Right percutaneous nephrolithotomy, right antegrade pyelogram, right renoscopy and proximal ureteroscopy, placement of 6 x 22 right ureteral stent in an antegrade fashion, placement of 22-French Councill tip catheter and nephrostomy tube.
DRAINS: A 6 x 22 double-J ureteral stent, a 22-French Councill tip catheter, 16-French Foley catheter.
INDICATIONS FOR PROCEDURE: 65-year-old female with a history of right staghorn calculus. She became septic placement of nephroureteral stent. However, she has improved, and she presents for surgical intervention today.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient. She was then taken back to the Operative Suite and anesthesia was induced without incident. She was placed in the prone position, taking care to pad all pressure points. She was given perioperative antibiotics. She was then prepped and draped in the sterile fashion. At this point in time, a scout fluoroscopy was taken showing nephroureteral stent in place and the staghorn calculus also noted. It was very opaque. A ephrostogram was showing moderate hydroureteronephrosis. An Amplatz Super Stiff Guidewire was advanced into the nephroureteral stent down to the bladder under fluoroscopic vision and the nephroureteral stent removed. A dual-lumen access sheath was inserted, and a second Amplatz Super Stiff Guidewire was inserted. A #15 blade scalpel was used to incise the entry of the nephrostomy tube site to allow access to the dilator. A 30-French NephroMax balloon dilator was then advanced with the proximal tip in the renal pelvis. The balloon was dilated [1 to 14 mmHg under fluoroscopic vision until fascial waist was adequately dilated. The access sheath was slid over the balloon liner into the proximal renal pelvis, and the balloon was removed. The nephroscope was inserted, and the stone was immediately visualized. The stone was removed using a combination of ultrasonic lithotripsy. All the fragments were irrigated out. There was a residual stone fragment in the right lower pole I was unable to access with the nephroscope, and thus the nephroscope was exchanged for a flexible cystoscope, and a renoscopy and proximal ureteroscopy was performed showing no fragments. The scope was inserted into the right lower pole and using the 2651 micron holmium laser fiber, the stone was ablated into multiple smaller fragments. These were removed using a combination of basket extraction and percutaneous ultrasonic lithotripsy. A repeat renoscopy did not show any evidence of calculi, and bleeding was minimal. There was no extravasation of urine from the renal pelvis by nephrostogram.
Once I was satisfied that I had removed the patient's stone burden, the cystoscope was removed and a 6 x 22 double-J ureteral stent was inserted into the right ureteral system. Good curl in renal pulse pelvis and the bladder. This was done under direct and fluoroscopic vision. The wire was removed, leaving one final Amplatz guidewire on which a 22-French Councill tip catheter was advanced over with the tip in the renal pelvis. The balloon was inflated to 3 cc. Nephrostogram showed no extravasation of urine. Once I was satisfied with the placement, all wires and the access sheath were removed. The Councill tip catheter acting as nephrostomy tube was secured to the patient's flank with 2-0 silk suture. The wound was then dressed with ABD pads The patient was returned to the Post Anesthesia Care Unit in stable condition.