prideandjy2003
Contributor
In the operative note below, I think the right ureteroscopy should be billable because all of the interventions are done on the left (except for the stent insertion, 52332, which there is no bundling issues with 52351). But, 52351 is not allowed with the other codes, even with a modifier. Is the right ureteroscopy separately billable? I greatly appreciate any help or insight!
PREOPERATIVE DIAGNOSES:
1. Right hydronephrosis.
2. History of stones and stricture.
3. Bilateral renal stones.
4. Possible left distal ureteral stone.
POSTOPERATIVE DIAGNOSES:
1. Right hydronephrosis.
2. Left ureteral stones and renal stone.
PROCEDURE:
1. Cystoscopy.
2. Bilateral retrograde pyelograms.
3. Bilateral ureteroscopy.
4. Retrieval of distal left ureteral stones and laser of left ureteropelvic/renal
stone.
5. Insertion of bilateral double J stents.
ANESTHESIA: Spinal.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Crystalloid.
DRAINS:
1. 6 x 22 cm double J stent on the right side.
2. 6 x 24 cm double J stent on the left side.
3. 18-French Foley catheter.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: After induction of anesthesia and normal sterile prep
and drape, we obtained a scout film that failed to identify any stones along the
path of the ureter on the right side, but suggested that at least one calcification
could be a stone in the distal left ureter. Cystoscopy was performed with a
22-French scope using 30 degree lens. We turned our attention to the right side
first and we saw the right ureteral orifice which was wider secondary to previous
meatotomy. The Sensor wire went up easily. We did not get a gush of cloudy or
problematic urine. We then used a 60-French open-ended catheter and instilled
contrast in the collecting system, showing it to be very hydronephrotic with a
somewhat tortuous ureter. The wire was replaced up into the kidney. A dual lumen
catheter easily went up, and we placed the second wire there. Then we drove a
7-French semi-rigid ureteroscope up the ureter and saw that the distal ureter was
not stenotic, easily appeared open. There were no stones. There was no debris.
The ureter, itself, while dilated, did not have any other problems. We removed the
scope and one of the wires and left the other until the end of the case. We then
turned our attention to the left side. Through the cystoscope we placed a wire up
the left side without any difficulty, appearing to go up to the kidney. We then
drove the 7-French semi-rigid ureteroscope up the ureter, and in the distal ureter
we encountered what turned out to be a pair of stones that were sizeable. We used
the escape basket to retrieve them individually and sent them for stone analysis.
We then drove up the ureter all the way to the kidney. There was some tortuosity
there, almost like she may have somewhat of a secondary UPJ on that side. We
identified a stone just inside the renal pelvis. We used the 200 micron fiber for
the Holmium Yag laser and performed laser lithotripsy, breaking this up into
sand-like debris. We then removed the ureteroscope, opacified the collecting
system through the ureteroscope with Conray, to which we added 80 mg of gentamicin,
which was the same as we had used on the other side. The collecting system here
was certainly somewhat dilated, and we then removed the ureteroscope.
We placed a 6-French x 22 cm double J stent over the wire on the right side and had
nice curls on both ends. We left the string dangler tucked in the vagina. On the
left side we placed a 6-French x 24 cm double J stent and had nice curls on both
ends. Again, a string was left tucked at the vagina. We placed an 18-French Foley
catheter in the bladder and sent the patient to the recovery room in excellent
condition. Ancef 1 gm was given preoperatively, and the patient was already on
ceftriaxone.
PREOPERATIVE DIAGNOSES:
1. Right hydronephrosis.
2. History of stones and stricture.
3. Bilateral renal stones.
4. Possible left distal ureteral stone.
POSTOPERATIVE DIAGNOSES:
1. Right hydronephrosis.
2. Left ureteral stones and renal stone.
PROCEDURE:
1. Cystoscopy.
2. Bilateral retrograde pyelograms.
3. Bilateral ureteroscopy.
4. Retrieval of distal left ureteral stones and laser of left ureteropelvic/renal
stone.
5. Insertion of bilateral double J stents.
ANESTHESIA: Spinal.
ESTIMATED BLOOD LOSS: Minimal.
FLUIDS: Crystalloid.
DRAINS:
1. 6 x 22 cm double J stent on the right side.
2. 6 x 24 cm double J stent on the left side.
3. 18-French Foley catheter.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: After induction of anesthesia and normal sterile prep
and drape, we obtained a scout film that failed to identify any stones along the
path of the ureter on the right side, but suggested that at least one calcification
could be a stone in the distal left ureter. Cystoscopy was performed with a
22-French scope using 30 degree lens. We turned our attention to the right side
first and we saw the right ureteral orifice which was wider secondary to previous
meatotomy. The Sensor wire went up easily. We did not get a gush of cloudy or
problematic urine. We then used a 60-French open-ended catheter and instilled
contrast in the collecting system, showing it to be very hydronephrotic with a
somewhat tortuous ureter. The wire was replaced up into the kidney. A dual lumen
catheter easily went up, and we placed the second wire there. Then we drove a
7-French semi-rigid ureteroscope up the ureter and saw that the distal ureter was
not stenotic, easily appeared open. There were no stones. There was no debris.
The ureter, itself, while dilated, did not have any other problems. We removed the
scope and one of the wires and left the other until the end of the case. We then
turned our attention to the left side. Through the cystoscope we placed a wire up
the left side without any difficulty, appearing to go up to the kidney. We then
drove the 7-French semi-rigid ureteroscope up the ureter, and in the distal ureter
we encountered what turned out to be a pair of stones that were sizeable. We used
the escape basket to retrieve them individually and sent them for stone analysis.
We then drove up the ureter all the way to the kidney. There was some tortuosity
there, almost like she may have somewhat of a secondary UPJ on that side. We
identified a stone just inside the renal pelvis. We used the 200 micron fiber for
the Holmium Yag laser and performed laser lithotripsy, breaking this up into
sand-like debris. We then removed the ureteroscope, opacified the collecting
system through the ureteroscope with Conray, to which we added 80 mg of gentamicin,
which was the same as we had used on the other side. The collecting system here
was certainly somewhat dilated, and we then removed the ureteroscope.
We placed a 6-French x 22 cm double J stent over the wire on the right side and had
nice curls on both ends. We left the string dangler tucked in the vagina. On the
left side we placed a 6-French x 24 cm double J stent and had nice curls on both
ends. Again, a string was left tucked at the vagina. We placed an 18-French Foley
catheter in the bladder and sent the patient to the recovery room in excellent
condition. Ancef 1 gm was given preoperatively, and the patient was already on
ceftriaxone.