- Messages
- 2
- Best answers
- 0
I am unsure how to code this uneventful PCNL, I want to just use a 52351 but the physician did not use a cystoscope. This is the OP note:
Procedure Details:
After appropriate consent and timeout patient was induced under anesthesia without
complication. 2 g Ancef administered as prophylaxis. Foley catheter placed via sterile
technique. He was then position prone in modified superman position with all pressure points
padded and prepped and draped usual sterile fashion for PCNL on the right side.
lnterventional radiology team gained access into the kidney and then nephroscopy took place.
I was unable to locate the patient's 1 cm stone. Anterior grade pyelogram did not demonstrate
filling defect, was unable to demonstrate filling defect in the ureter fluoroscopically either.
Using one of the safety wires I advanced the ureteroscope over the wire down the ureter and
was unable to identify a stone, there was resistance at the proximal ureter but I was unable to
visualize its etiology. At this point my portion of the case was terminated, plan was to leave
that with interventional radiology team to place a nephroureteral stent and we will plan to
repeat image the patient. As per preoperative discussion with the patient and postoperative
discussion with his wife, we will send the patient home as intervention and bleeding were
exceedingly minimal today. He tolerated the procedure well there were no acute
complications. He was awoke from anesthesia and transferred to PACU in stable condition.
Findings:
Unable to locate stone
Specimen Removed:
* No specimens in log *
Estimated Blood Loss:
Minimal
Complications:
None
Does anyone have any thoughts or guidance?
Procedure Details:
After appropriate consent and timeout patient was induced under anesthesia without
complication. 2 g Ancef administered as prophylaxis. Foley catheter placed via sterile
technique. He was then position prone in modified superman position with all pressure points
padded and prepped and draped usual sterile fashion for PCNL on the right side.
lnterventional radiology team gained access into the kidney and then nephroscopy took place.
I was unable to locate the patient's 1 cm stone. Anterior grade pyelogram did not demonstrate
filling defect, was unable to demonstrate filling defect in the ureter fluoroscopically either.
Using one of the safety wires I advanced the ureteroscope over the wire down the ureter and
was unable to identify a stone, there was resistance at the proximal ureter but I was unable to
visualize its etiology. At this point my portion of the case was terminated, plan was to leave
that with interventional radiology team to place a nephroureteral stent and we will plan to
repeat image the patient. As per preoperative discussion with the patient and postoperative
discussion with his wife, we will send the patient home as intervention and bleeding were
exceedingly minimal today. He tolerated the procedure well there were no acute
complications. He was awoke from anesthesia and transferred to PACU in stable condition.
Findings:
Unable to locate stone
Specimen Removed:
* No specimens in log *
Estimated Blood Loss:
Minimal
Complications:
None
Does anyone have any thoughts or guidance?