hope19761
New
I need to know if there a billable code for the aspiration performed along with the Ureteroscopy. (see underline portion of op note).
PREOPERATIVE DIAGNOSIS: Left ureteral calculus. POSTOPERATIVE DIAGNOSIS: Left ureteral calculus. PROCEDURE:
1. Cystourethroscopy.
2. Left retrograde ureteral pyelogram under fluoroscopic guidance.
3. Left stent placement. COMPLICATIONS: None. FINDINGS: Gross pyuria.
PERTINENT HISTORY: The patient is a 42-year-old female with history of left flank pain and history of left ureteral calculus measuring 18 x 9 mm.
OPERATIVE PROCEDURE: The patient was identified in the holding area. After obtaining informed consent, the patient was brought to the operating suite and placed in supine position. Following administration of general endotracheal anesthesia, patient was placed in lithotomy position and perineum was prepped and draped in a sterile fashion. A 21-French cystourethroscopy was performed. One drop of purulent debris was noted at the level of the left ureteral orifice and appeared to be stagnant in that position. A retrograde was then performed using a cone tip catheter through the left ureteral orifice and there was a stone noted in the proximal portion ureter, which appeared to be radiolucent. At this point, there was no drainage of purulent debris and a flexible ureteroscope was introduced into the level of the left kidney obstructive features. At this point, there was no irrigation and no visualization noted within the collecting system an 10cc syringe was utilized to aspirate fluid. The fluid was murky and cloudy consistent with gross pyuna and pyonephrosis. At this point, the scope was immediately withdrawn. No pressure irrigation was applied. No irrigation of the upper collecting system was utilized whatsoever. At this point, a 6 x 24 double J stent was placed in routine fashion over a glide wire. KUB showed good positioning of the stent within the collecting system. The bladder was drained. The patient was taken to the recovery room in stable condition.
PREOPERATIVE DIAGNOSIS: Left ureteral calculus. POSTOPERATIVE DIAGNOSIS: Left ureteral calculus. PROCEDURE:
1. Cystourethroscopy.
2. Left retrograde ureteral pyelogram under fluoroscopic guidance.
3. Left stent placement. COMPLICATIONS: None. FINDINGS: Gross pyuria.
PERTINENT HISTORY: The patient is a 42-year-old female with history of left flank pain and history of left ureteral calculus measuring 18 x 9 mm.
OPERATIVE PROCEDURE: The patient was identified in the holding area. After obtaining informed consent, the patient was brought to the operating suite and placed in supine position. Following administration of general endotracheal anesthesia, patient was placed in lithotomy position and perineum was prepped and draped in a sterile fashion. A 21-French cystourethroscopy was performed. One drop of purulent debris was noted at the level of the left ureteral orifice and appeared to be stagnant in that position. A retrograde was then performed using a cone tip catheter through the left ureteral orifice and there was a stone noted in the proximal portion ureter, which appeared to be radiolucent. At this point, there was no drainage of purulent debris and a flexible ureteroscope was introduced into the level of the left kidney obstructive features. At this point, there was no irrigation and no visualization noted within the collecting system an 10cc syringe was utilized to aspirate fluid. The fluid was murky and cloudy consistent with gross pyuna and pyonephrosis. At this point, the scope was immediately withdrawn. No pressure irrigation was applied. No irrigation of the upper collecting system was utilized whatsoever. At this point, a 6 x 24 double J stent was placed in routine fashion over a glide wire. KUB showed good positioning of the stent within the collecting system. The bladder was drained. The patient was taken to the recovery room in stable condition.