I would like coding suggestion for the following excerpt from a chart note. I am kind of at a loss. Thank you.
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"Procedure: cystoscopy
After informed consent, she was placed in the supine position and prepped and draped in the usual manner around the ileal conduit. The flexible cystoscope with video guide was placed into the abdominally located conduit.
TheStoma was found to be stenosed. Therefore, Hegar dilators were used to dilate the stoma to a 24 French size without difficulty.
Findings:
ileal conduit
Mucosal lesions: No Glomerulations. Erythematous patches not present. Raised lesions not present. Foreign bodies not present
Capacity: Normal
Specimen for culture: not obtained
Barbotage specimen for cytology: Not obtained
A 22 French catheter was placed into the conduit and the balloon filled with approximately 5 cc of sterile water. The catheter was then placed into the drainage bag. This will remain in place for one week to allow for dilation."
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"Procedure: cystoscopy
After informed consent, she was placed in the supine position and prepped and draped in the usual manner around the ileal conduit. The flexible cystoscope with video guide was placed into the abdominally located conduit.
TheStoma was found to be stenosed. Therefore, Hegar dilators were used to dilate the stoma to a 24 French size without difficulty.
Findings:
ileal conduit
Mucosal lesions: No Glomerulations. Erythematous patches not present. Raised lesions not present. Foreign bodies not present
Capacity: Normal
Specimen for culture: not obtained
Barbotage specimen for cytology: Not obtained
A 22 French catheter was placed into the conduit and the balloon filled with approximately 5 cc of sterile water. The catheter was then placed into the drainage bag. This will remain in place for one week to allow for dilation."