Kathryn M. Foss
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Please advise correct coding for urologist for the following scenario:
A 14-French flexible scope was inserted in pt.'s urethral meatus. She was scoped in the usual fashion w/the following findings: urethra, bladder & UO all normal. Following inspection of bladder mucosa the 0.038 sensor tip wire was advanced w/out difficulty up LT ureter to approx. 30 cm. Scope was withdrawn & a ureteral occlusion balloon catheter was advanced approx. 10 cm up the ureter over the guidewire w/out difficulty, guidewire was withdrawn. Occlusion balloon was inflated to 2 mL, hooked up to a syringe w/contrast. Pt. was then placed in prone position on the fluoroscopy table & her back was prepped & draped. Interventional radiologist then attempted LT PCNL however the access could not be achieved. We attempted to dilate the collecting system by injecting contrast through the occlusion catheter but it became apparent that there was extravasation of urine in or around the pelvic ureter. A guidewire was advanced up to the level of the mid ureter but would not advance beyond that-it was felt to be extraluminal, the wire was left in place. The guidewire or the ureteral catheter was withdrawn after deflating the balloon and the a catheter was advanced into the pelvic ureter. A flexible SuperSlick guidewire was then advanced up the ureter from the distal pelvic ureter beyond the extravasation & curing nicely in the renal pelvis. A 6-French 26 cm JJ stent was then advanced & the procedure was terminated.
Is the stent placement the only reportable procedure for the urologist?
Thank you in advance for any assistance!
A 14-French flexible scope was inserted in pt.'s urethral meatus. She was scoped in the usual fashion w/the following findings: urethra, bladder & UO all normal. Following inspection of bladder mucosa the 0.038 sensor tip wire was advanced w/out difficulty up LT ureter to approx. 30 cm. Scope was withdrawn & a ureteral occlusion balloon catheter was advanced approx. 10 cm up the ureter over the guidewire w/out difficulty, guidewire was withdrawn. Occlusion balloon was inflated to 2 mL, hooked up to a syringe w/contrast. Pt. was then placed in prone position on the fluoroscopy table & her back was prepped & draped. Interventional radiologist then attempted LT PCNL however the access could not be achieved. We attempted to dilate the collecting system by injecting contrast through the occlusion catheter but it became apparent that there was extravasation of urine in or around the pelvic ureter. A guidewire was advanced up to the level of the mid ureter but would not advance beyond that-it was felt to be extraluminal, the wire was left in place. The guidewire or the ureteral catheter was withdrawn after deflating the balloon and the a catheter was advanced into the pelvic ureter. A flexible SuperSlick guidewire was then advanced up the ureter from the distal pelvic ureter beyond the extravasation & curing nicely in the renal pelvis. A 6-French 26 cm JJ stent was then advanced & the procedure was terminated.
Is the stent placement the only reportable procedure for the urologist?
Thank you in advance for any assistance!