...."A 22-French rigid cystoscope was placed into the bladder. No obvious
urethral or bladder lesions were noted. Some inflammation was noted around the
right ureteral orifice. Left ureteral orifice was normal. A 5-French
open-ended catheter was placed into the right ureter. Retrograde pyelogram
revealed a slight dilatation of the right ureter with some blunting of the right
calices. A questionable filling defect was noted in the mid ureter. At this
point, a 0.038 hybrid guidewire was placed in the right kidney. The right
ureteral orifice and distal ureter were dilated to a size 12-French with the
ureteral dilator and then a 6-French self-dilating ureteroscope was advanced.
Some inflammation again was noted in the distal ureter; however, there was no
stone noted and the ureter was clear up to the level of the UPJ. Adequate
drainage was noted from the right kidney, so the stent was not placed.
...."
If a physician uses a self-dilating ureteroscope, what CPT best describes that procedure?
Do I use 52351?
The only codes I see for dilating the ureter is done to treat a stricture and there's no mention of that in OP note. Also, he didn't use balloon dilation, laser, electrocautery, and incision as stated in the OP note.
Please advise.
Thanks,
Brandi
urethral or bladder lesions were noted. Some inflammation was noted around the
right ureteral orifice. Left ureteral orifice was normal. A 5-French
open-ended catheter was placed into the right ureter. Retrograde pyelogram
revealed a slight dilatation of the right ureter with some blunting of the right
calices. A questionable filling defect was noted in the mid ureter. At this
point, a 0.038 hybrid guidewire was placed in the right kidney. The right
ureteral orifice and distal ureter were dilated to a size 12-French with the
ureteral dilator and then a 6-French self-dilating ureteroscope was advanced.
Some inflammation again was noted in the distal ureter; however, there was no
stone noted and the ureter was clear up to the level of the UPJ. Adequate
drainage was noted from the right kidney, so the stent was not placed.
...."
If a physician uses a self-dilating ureteroscope, what CPT best describes that procedure?
Do I use 52351?
The only codes I see for dilating the ureter is done to treat a stricture and there's no mention of that in OP note. Also, he didn't use balloon dilation, laser, electrocautery, and incision as stated in the OP note.
Please advise.
Thanks,
Brandi