Urinary Bladder slide14 - AAPC
Documentation Dissection
Urinary¡ªOperative Report
PREOPERATIVE DIAGNOSIS: Right ureteropelvic junction obstruction.
POSTOPERATXVE DIAGNOSIS: Right ureteropelvic junction obstruction |1|
PROCEDURES PERFORMED: Cystoscopy, right retrograde pyelogram, and removal of right double J stent |2|
SURGEON:
HISTORY: The patient has had a laparoscopic right pyeloplasty, he had obstruction afterwards. His nephrostomy tube became
dislodged and a second nephrostomy tube and double-J stent wag added then it is time now to remove his double J stent from
the right side |3|. Discussion has been held with his mother about indications, alternatives, and risks of surgery. She seems to
understand these issues and has given consent for this procedure.
DETAILS OF PROCEDURE: With the patient under adequate general anesthesia, after a timeout was taken in the dorsal
lithotomy position, he was scrubbed, prepped, and draped in a sterile fashion. Then, the meatus was dilated to 16 French and a 14
French cystoscope was passed through the urethra into the bladder. The bladder was briefly examined and the left sidewall of the
bladder had an erythematous patch on it and there was swelling around the right ureteral orifice. Then, the graspers were placed
through the cystoscope and the stent was grasped at the end and removed |4|. Then, the cystoscope was repassed and a 3 French
whistle-tip was passed up the right ureter and fluoroscopy showed that the ureter was patent and normal. The UPJ did not fill out
well and seemed to still have some significant swelling and the pelvis seem to have blood clot within it. Then, the double-J stent was
removed, the bladder was emptied, and the cystoscope was removed. Xylocaine 2% jelly was placed in the urethra and he was taken
out of the lithotomy position and awakened and sent to the recovery room in good condition. All needle and sponge counts were
correct. The estimated blood loss was minimal.
_____________________________________________________________
|1|
Diagnosis for reporting.
|2|
Procedure planned.
|3|
Stent¡ªright side¡ªremoved.
|4|
Stent removed with cystoscope.
_____________________________________________________________
What are the CPT? and ICD-10-CM codes reported?
CPT? Code: 52310-RT
ICD-10-CM Code: N13.5
Rationales:
CPT?: Look in CPT? Index for Cystourethroscopy/Removal/Foreign Body reporting code 52310. 52315 is for a complicated
procedure, which is not supported by documentation. Modifier RT is used since this is the right side.
ICD-10-CM: Look in the Alphabetical Index for Obstruction/ureter leading to N13.5. Verify in Tabular List, N13.5, crossing vessel
and stricture of ureter without hydronephrosis is confirmed.
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