Documentation Dissection - AAPC

Documentation Dissection

Urinary¡ªOperative Report

PREOPERATIVE DIAGNOSIS: Left ureteropelvic Junction obstruction.

POSTOPERATIVE DIAGNOSIS: Left ureteropelvic junction obstruction, congenital |1|.

OPERATION PERFORMED: Cystourethroscopy with left retrograde pyelogram, and insertion of a left 6 x 22 double J ureteral

stent and laparoscopic left dismembered pyeloplasty |2|.

ANESTHESIA: General endotracheal anesthesia.

ESTIMATED BLOOD LOSS: 10 mL.

COMPLICATTONS: None.

SPECIMENS: Left renal pelvis |3|.

DRAINS: 6 x 22 double-J ureteral stent on a string.

HISTORY OF PRESENT ILLNESS: The patient is a 3-year-old male who presented to an outside facility last week with severe left

flank pain and required hospitalization for pain management |4|. CT scan revealed severe hydronephrosis |5| with crossing vessels.

The inferior aspect of the renal pelvis suspicious for crossing vessels causing UPJ obstruction. The patient was therefore sent out to

be seen by us. After discussion of risks and benefits of the procedure, the parents and the patient elected to proceed.

DESCRIPTION OF PROCEDURE: Appropriate consent was obtained. Preoperative antibiotics were given in the form of

Ancef. The patient was brought back to the operating suite and placed in the dorsal lithotomy position after general endotracheal

anesthesia that had been induced. He was prepped and draped in normal sterile fashion. We used a 17 French cystoscope |6| to

cannulate the patient¡¯s urethra and bladder. Bilateral ureteral orifices were in the normal anatomic location and appeared normal.

There were no abnormalities seen inside the bladder. We inserted a Kumpe catheter first into the left ureteral orifice and performed

a left retrograde pyelogram |7|. Findings showed a normal caliber ureter with a stenotic segment at the ureteropelvic junction

and massive hydronephrosis of the left renal pelvis |7|. We were able to place a PTFE guidewire through the Kumpe catheter and

backloaded off the Kumpe catheter and placed the Pollock catheter under fluoroscopic guidance to the renal pelvis |8|. We left this

in place and Tegaderm at the tip of the penis. We then broke scrub and repositioned the patient in the flank position with the left

side up. Pressure points were all appropriately padded. He was reprepped and draped. We first gained access to the peritoneum

through the umbilicus with a Veress needle |9|. Saline drop test was performed and we then insufflated the abdomen. We then

inserted the camera port and camera and inspected the abdomen. No intraabdominal injury was identified. However some of the

omentum had received some insufflation. We then inserted 2 other 5 mm ports under direct vision, 1 in the right lower quadrant

and one that was superior and lateral to the umbilical port. Due to his prior Nissen fundoplication and scarring, did not go directly

in the midline. We then filled the renal pelvis with saline by injecting through our previously placed Pollock catheter. When this

was performed we were able to see a bulge through the mesentery that was draped over the renal pelvis. We felt that this gave us

adequate access to the renal pelvis and therefore elected to make a transmesenteric window to come down on the renal pelvis. We

did this using Maryland dissectors and laparoscopic scissors and electrocautery as needed. We were able to grasp the renal pelvis

and pulled out through the mesenteric window. We identified the ureteropelvic junction as well. Once we had dissected out the

renal pelvis adequately, we used a Keith needle to go transcutaneously through the renal pelvis and then back through the skin

and a hemostat was placed as a holding stitch to elevate the renal pelvis. We were able to dissect off the ureter and as we followed

the ureter distally, we saw the crossing vessels that had been seen previously on imaging |10|. We then dissected more distal on the

ureter so to bring it out on the other side of crossing vessels. Once this was isolated, we transected the UPJ and then spatulated

the ureter laterally. We brought the ureter up and transposed the ureter over the top of these crossing vessels. We then used a 5-0

Vicryl running stitch to perform our anastomosis of the ureter to the renal pelvis. We began at the apex of the ureter, the inferior

aspects of the ureter along with spatulated incision and dissected interiorly into the renal pelvis. We then used two different

stitches, one coming medially on the ureter to posterior and one lateral to posterior. When this was completed, we finished the

anastomosis of the ureter, and then we tied the two sutures to themselves and then to each other. We then performed a reduction

pyeloplasty by excising a large part of redundant renal pelvis. Some of this was passed off as specimen |11|. Prior to closing the

renal pelvis, we passed a PTFE guidewire up the Pollock catheter and backloaded off the Pollack catheter. We then passed the 6 x

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22 double J stent up the guidewire until it was visualized to curl in the renal pelvis |12|. The string was left on the stent to come out

of the patient¡¯s urethra. The wire was removed as well as the pusher and the double-J stent was curling nicely in the renal pelvis.

We then closed the renal pelvis defect with a running 5-0 Vicryl stitch. Once this was performed, we removed the stay stitch

and assessed for hemostasis. Hemostasis was apparent. We looked for any other intra-abdominal injury and there was none. We

suctioned out any excess fluid. We then closed the port site. We then removed the port site. We then desufflated the abdomen again

assessed for hemostasis and no active bleeding was identified. We then removed our ports and closed the port sites with 3-0 Vicryl

for fascia and 5-0 Monocryl for skin. The string on the stent was taped to the patient¡¯s penis. He came out of anesthesia without any

complications, transferred to the PACU in stable condition.

_____________________________________________________________

|1|

Obstruction of left ureteropelvic junction.

|2|

Procedure performed.

|3|

Pathology of left renal pelvis.

|4|

Indication of the symptoms the patient is having.

|5|

Hydronephrosis confirmed on CT scan.

|6|

Cystoscopy performed.

|7|

Pyelogram performed. Showed stenosis at ureteropelvic junction and hyrdronephrosis.

|8|

Fluoroscopic guidance for the catheter placement.

|9|

Indicates a laparoscopic procedure.

|10|

The crossing vessels are confirmed.

|11|

Pathology specimen¡ªreduction pyeloplasty.

|12|

Stents and catheters placed.

_____________________________________________________________

What are the CPT? and ICD-10-CM codes reported?

CPT? Codes: 50544-LT, 52332-51-LT, 74420-26

ICD-10-CM Codes: Q62.39, Q62.0

Rationales:

CPT?: In the CPT? Index, look for Pyeloplasty leading to 50400¨C50405, 50544. Instructional note at 50400¨C50400 states for

laparoscopic approach use 50544. This is a unilateral code and was performed on the left side. Modifier LT is added.

In the CPT? Index, look for Cystourethroscopy/Insertion/Indwelling Ureteral Stent referring you to 50947 and 52332. 52332

describes a cystourethroscopy, with insertion of indwelling ureteral stent (double-J type). Modifier 51 is appended to denote

additional procedures performed during the same session. Modifier LT is used for the stent placement in the left ureter.

In the CPT? Index, look for Pyelogram referring you to see Urography, Intravenous; Urography Retrograde. Look for Urography/

Retrograde referring you to 74420. Modifier 26 is used for the professional component. The equipment is the expense of the facility.

ICD-10-CM: The UPJ is considered congenital, or present at birth. Look in the ICD-10-CM Alphabetic Index for Obstruction/

ureter (functional) (pelvic junction)/congenital Q62.39. Look in the Alphabetic Index for Hydronephrosis/Congenital leading to

Q62.0. Verify code selection in the Tabular List.

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