I am wondering if anyone is billing for 2 urologists, same practice, performing CPT 50081. I know mod 62 is for co-surgeon, but they are in the same practice and I don’t believe it will apply. Both surgeons are dictating their own OP reports and listing each other as assistants. They want to each bill for their own part, but I don’t believe they can. I am including both of their OP reports below. I know this is confusing. I have been working with both of them to get this sorted out. Any help with suggestions for them and correct codes would be greatly appreciated.

Thanks,

Kelly – CPC

Operation #1

Nephrolithotomy Percutaneous, CYSTOSCOPY, URETEROSCOPY LASER LITHOTRIPSY, STENT PLACEMENT, LEFT PERCUTANEOUS NEPHROLITHOTOMY, Left

1. Left flexible ureteroscopy with stone manipulation
2. Insert left double-J stent 6 x 26 cm
3. Fluoroscopy

Surgeon
1. Dr. Smith

Assistant
2. Dr. Jones

Technique

As part of patient’s complete operation patient was prepped and draped in the prone position after successful induction of general anesthesia. Cystoscopy was performed with the rigid 22 French scope and 30° lens. The left ureteral orifice was cannulated with a 6 French ureteral injection catheter. Through the catheter was then placed a 0.035 sensor wire. Instruments were removed leaving the sensor wire in place. Over the sensor wire using fluoroscopy the left lower ureteral mid ureteral segments were dilated with the dual lumen 10 French injection catheter. A second sensor wire was placed through the second port in the dual lumen catheter removed. Over one of the sensor wires was "monorailed" the Olympus digital flexible ureteroscope. The scope encountered obstruction at the mid ureter due to encrusted material from the previous nephrostomy tube. By removing the guidewire and the scope was able to be manipulated all the way up into the kidney. The large renal pelvic stone had to be manipulated out of the way in order to push the scope all the way into the dilated mid pole calyx where upon using fluoroscopy guidance Dr. Jones then was successful in obtaining percutaneous access for the PCNL procedure. During the PCNL procedure stones were manipulated so as to capture all the available stone in the renal pelvis.

Once the bulk of the stone was disintegrated and extracted, ureteroscope was then manipulated into lower pole calyx where upon a second percutaneous procedure and access needle was placed by Dr. Jones. A second PCNL of the lower pole stones was carried out uneventfully by Dr. Jones. On completion of the second access PCNL, a Glidewire was inserted through the ureteroscope after injection pyelogram. Over the Glidewire was placed a 6 x 26 cm double-J stent which coiled in the right renal pelvis and the distal end called nicely in the bladder. Fluoroscopy confirmed excellent placement of the stent. A Foley catheter was placed and left to gravity drainage as a procedure was terminated. There were no complications.

Signed….Dr. Smith

Operation # 2

Nephrolithotomy Percutaneous, CYSTOSCOPY, URETEROSCOPY LASER LITHOTRIPSY, STENT PLACEMENT, LEFT PERCUTANEOUS NEPHROLITHOTOMY, Left

I, Dr. Jones, will dictate the percutaneous nephrolithotomy portion of the procedure. Dr. Smith will dictate ureteroscopy.

Surgeon(s)
Dr. Jones

Assistant
Dr. Smith

Technique

after satisfactory induction of general anesthesia and endotracheal intubation with the patient was placed in a prone position on the operating table with all pressure points padded. Leg spreaders were utilized to allow access to the bladder. Timeout was performed. Appropriate antibiotics verified.the patient underwent cystoscopy and ureteroscopy by Dr. Paul Smith which will be dictated separately. Once the appropriate area for planned entry into the left collecting system was chosen utilizing the tip of the nephroscope as a target the patient had a needle placed and entered into the collecting system under direct vision with the ureteroscope. A wire was then placed through this needle and followed down into the ureter and out the urethra and became a through and through safety wire. Over this wire a fascial dilator was utilized followed by 8/10 ureteral dilating set. A second wire was then placed into the collecting system but did not pass all the way down the ureter.This wire was utilized for balloon dilatation. The balloon was dilated to 12 atm then reduced to 10 atm under fluoroscopic vision and the renal access sheath was placed over the balloon and into the collecting system. Both the balloon dilatation and the sheath were performed under direct vision from the ureteroscope. Minimal bleeding was encountered. The stones were identified and treated sequentially with the cyber wand. Larger fragments were removed. The remainder the stone was treated with the cyber wand and fragments sent for permanent section. There was no evidence of injury to the collecting system or ureter and the ureteroscope monitored the case demonstrating no significant fragments from below.

Then decided we would attempt another access point to treat the stones in the lower pole as the vectors were not appropriate for treatment of these stones through the current nephrostomy tract. Similarly the site was chosen over the lower pole stone collection and entered and a exact manner as described above. The nephroscope was introduced and all of the stones in this case were able to be removed through the nephroscope without the need for lithotripsy. No active bleeding. It should be noted that the balloon dilatation and placement of the sheath occurred over one guidewire which could not be passed down the ureter.after this portion was completed the sheath was removed with no active bleeding.

Now that all of the stones which couldn’t be reached were treated we set about draining the urinary system. From below Dr. Smith placed a 26 cm x 6 French double-J stent noted be in good position by fluoroscopy. Also I was able to watch the kidney end of the curl developed with the nephroscope. through the remaining sheath I placed a 20 French council tip catheter under fluoroscopic guidance and performed a nephrostogram and based on the nephrostogram placed the catheter in a position that would not occlude the lower pole collecting system and the patient had 2-1/2 cc of contrast mixed with normal saline placed in the balloon and the catheter was sutured to the skin after the sheath was cut away. This skin wound was closed with a nylon and the tube secured with the same nylon to the skin. It was placed to gravity drainage. The attention was then turned to the lower pole nephrostomy site which was closed with interrupted Monocryl subcuticular. Dry sterile dressings were applied to both the sides. The patient had a Foley catheter placed. She is awake and transferred to the stretcher and taken the recovery room in stable condition.

signed by Dr. Jones