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Tag Archives: Ureteral

Trans-urethral resection of intra-bladder left ureteral…

Posted on by
Hello everyone! Was hoping someone can guide us in the right direction on this surgery. patient had a nephrectomy done a few days earlier. We are kinda stumped on this one. Thank you in advance :)

Procedure Name: Elective Cystoscopy, Trans-urethral resection of intra-bladder left ureteral inverted stump and fulguration of left ureteral orifice.

History: Intra-bladder inversion of left ureteral stump from prior ureteral avulsion.

Procedure Description: After informed consent was received patient was brought to the operating room and placed in a supine position. Anesthesia was induced. Patient was placed in a dorsal lithotomy position and genitals were prepped and draped in a standard fashion. Appropriate time out was performed. Cystoscopy revealed: Intra-bladder inversion of left ureteral stump from prior ureteral avulsion,
The ureteral stump were resected and the left ureteral orifice was then fulgurated. The ureter was sent to pathology for permanent examination. Hemostasis was achieved. Scope was removed and a Foley catheter was placed and was draining clear urine.

Medical Billing and Coding Forum

laparoscopic ureteral re-implantation, neo-cystotomy…

Posted on by
hello everyone!!! I was wondering if anyone can guide me in the right direction for this surgery that I have never coded :)

I was looking at maybe 50948-RT? Thank you in advance. I always get nervous with procedures I have not seen before.

Procedure Name: Elective Right robotic laparoscopic ureteral re-implantation, neo-cystotomy, bladder psoas hitch, right ureteral stent exchange.

Procedure Description: Pt was taken to the OR, induced under general anesthesia and then positioned in dorsal lithotomy. The pt was then repositioned into modified dorsal lithotomy position and placed in trendelenberg position. The pt was then prepped and draped. A robotic laparoscopic pelvic approach was utilized (5 ports – four 8mm ports, one 5mm port). The first port was placed using the veress needle and direct visual guidance. The remaining ports were placed under visual guidance. Attention was now focused on the right distal ureter. It was carefully dissected and ended into a scarred area near the pelvic brim. The bladder was also dissected free and a site on the dome chosen for the re-impant site. The distal right ureter was then ligated with care taken to preserve the ureteral stent. A psoas hitch was performed to bring the bladder dome to the right psoas muscle using a 2-0 vicryl suture. A small 1cm incision was created in the bladder dome as the site for the re-implant. The healthy proximal distal ureter was then re-anastomosed to this new bladder dome implant site using 2-0 vicryl sutures. A water tight anastomosis was created. The bladder was insufflated with indigo carmine tainted saline and no leak was noted. The bladder was drained. A lake drain was placed in the lower pelvis. The ports were then all removed and the wounds all closed. The skin closed was using 4-0 monocryl & skin glue.
The pt was then extubated and transferred to PACU/recovery in stable condition.

Medical Billing and Coding Forum

TURBT with ureteral biopsies

Posted on by
Looking for some advice on the following:

OPERATION: Cystoscopy, transurethral resection of bladder tumor,
right diagnostic ureteroscopy with biopsies of right distal ureter,
right retrograde pyelogram, and right ureteral stent change.

DESCRIPTION OF OPERATION:
The patient was identified in the waiting area and brought into the
room. Preoperative antibiotics consisting of Levaquin and
gentamicin were provided, and general anesthesia administered. The
patient was placed in lithotomy position, then prepped and draped in
a standard sterile surgical fashion. Time-out was performed.
Consent and laterality were verified. Cystoscopy was performed
using a 30-degree scope. No strictures in the anterior urethra.
Open prostatic fossa consistent with prior BPH surgery. The bladder
was entered. The patient had extensive grade 3 or 4 trabeculation
throughout the bladder along with diverticula in the posterior
aspect of the bladder. The stent was noted emanating from the right
ureteral orifice. Just above and lateral to the right ureteral
orifice, the patient had extensive inflammation with the medial part
of that inflammation suspicious for bladder cancer. This appears to
be the site of prior TURBT. At this point, I inserted a 26-French
resectoscope, and using sterile water with continuous irrigation, I
went ahead and resected the mass, which was extending close to the
right ureteral orifice along with the inflammation lateral to it.
This measured approximately 2.5 cm in total. The resection base was
cauterized. Next, the patient also was noted to have inflammation
extending more laterally. I did take a quick resection of that and
sent it for specimen to confirm this is not tumor. After confirming
there was no bleeding from the resection site and all the mass
fragments were evacuated using the Ellik evacuator, I reinserted the
22-French cystoscope and pulled the stent out of the urethral
meatus. A Sensor wire was then passed through the stent into the
right kidney. I then assembled a short rigid ureteroscope and
advanced it through the right ureteral orifice. I then performed a
retrograde study through the scope revealing a filling defect at the
area of the UVJ and concentric filling defects approximately 3 cm
proximal to the UVJ. I then inserted the ureteroscope through the
right ureteral orifice and inspected the ureter carefully. The
patient had inflammation at the area of the UVJ proximal to it and
some inflammatory protrusions about an inch from the UVJ. Proximal
to that, I inserted the scope and the mucosa appeared smooth without
any defect. I was able to pass the ureteroscope easily to the mid
ureter above the pelvic inlet. Retrograde revealed some
hydronephrosis without filling defect in the mid and proximal
ureter, and no obvious filling defects in the collecting system.
Next, a flexible biopsy cup was introduced through the ureteroscope
and 4 separate biopsies were performed from the UVJ inflammation
area as well as the concentric inflammation proximal to it. The
specimens were small and were handed to pathology for quick
processing. Reinspection revealed no active bleeding. I removed
the ureteroscope and using fluoroscopic guidance and cystoscopy,
placed a 6 x 26 stent over the wire. The stent was noted to coil
nicely in the kidney and in the bladder. Again inspection of the
bladder revealed no bleeding. A 20-French Foley catheter was
inserted and balloon inflated with 10 mL of sterile water. The
patient tolerated the procedure well.

I’ve come up with 52235 for the TURBT, 52354 for the ureteral biopsy, 52332 for stent change, and 74420-26 for the pyelogram. However, my encoder indicates that 52332 bundles into 52235 and 52235 itself bundles into 52354 (but 52332 does NOT bundle into 52354). Are any modifiers warranted here or should I just be billing 52354 & 74420-26? Any help would be appreciated. Thanks.

Medical Billing and Coding Forum

Cystoscopy with forceps manipulation of ureteral stent

Posted on by
Is there a code for the manipulation of a ureteral stent?

Procedure : Cystoscopy, forceps manipulation of left ureteral stent, replacement of indwelling Foley catheter
*
Details of Procedure: The patient was taken to the OR. Time-out completed. Sterilely prepped and draped in dorsal lithotomy position, and administered monitored anesthesia 30 degree cystoscope lens was passed with 22 French sheath into the bladder. Normal anterior urethra. Benign prostatic hyperplasia with obstruction and high bladder neck. The stent was visualized emanating from left ureteral orifice, and this was visualized fluoroscopically at the proximal end of the stent as well. With direct and fluoroscopic visualization, the stent was grasped initially with 30 and subsequently 70 degree lens and grasping forceps, and the stent was manipulated out distally to bring the curl of the stent back in the expected position of the left renal collecting system. Position appeared much improved. There was significant redundancy in the bladder once I then pushed the stent back using sheath of the cystoscope into the bladder, but we were very pleased with the overall position. The scope was withdrawn.
*
Fourteen French Foley catheter well lubricated was passed with sterile technique in the bladder, with return of clear irrigating fluid. 10 milliliter sterile water used to inflate balloon.

Thanks

Medical Billing and Coding Forum

CPT 52356 along with dilation for ureteral stenosis

Posted on by
I’m finding some conflicting information for this procedure whether the dilation would be separately billable.

Procedure: Urethral dilation, cystoscopy, right retrograde pyelogram, right ureteral dilation, right rigid ureteroscopy, right flexible digital ureteral pyeloscopy, laser lithotripsy of ureteral and renal calculi, placement of right double-J stent 6 x 26.

A 22-French cystoscope was then used to evaluate the patient. The patient was noted to have meatal stenosis. He underwent dilation of the fossa navicularis with Van Buren sounds up to 24-French.
*
A 22-French cystoscope was then used to evaluate the patient. The anterior urethra was normal in appearance without any evidence of stricture. His urethrovesical anastomosis was intact. Upon entering the bladder, both ureteral orifices were identified, appeared to be in orthotopic position with clear
efflux of urine. Systematic evaluation of the bladder with a 30- and 70-degree angle lens demonstrated no gross intravesical pathology. Specifically, no gross inflammation, tumor, or calculi.
*
A right retrograde pyelogram was performed. This demonstrated what appeared to be a stone near the iliac vessels. There was also evidence of calcification in the lower pole of the right kidney. The ureteral orifice was dilated with a Nottingham dilator. The cystoscope was then withdrawn.
*
A 6.9-French semi-rigid ureteroscope was then used to evaluate the patient. The distal ureter was normal in appearance up to the iliac vessels. The stone appeared to be proximal to the iliac vessels, but unfortunately, I was unable to navigate the semi-rigid ureteroscope proximal to the iliac vessels. At this point, an additional wire was then placed through the working port of the semi-rigid ureteroscope and the ureteroscope was withdrawn.
*
The digital ureteroscope was then advanced over the wire. We were able to identify the stone just proximal to the iliac vessels. Using the holmium laser, the stone was then dusted into multiple small fragments. The ureteroscope was then advanced at this point and a wire was placed through the digital ureteroscope and the ureteroscope was withdrawn. An 11 x 13 x 44 ureteral access sheath was then advanced. I was unable to advance the
ureteral access sheath proximal to the iliac vessels. Given this finding, I did place an additional wire, then advanced the ureteral scope into the right renal pelvis. The patient’s major stone burden was in the lower pole of the right kidney. The stone was then broken up into multiple small fragments. These fragments were too small to engage in a Nitinol basket. Systematic evaluation on remainder of the calyces demonstrated no evidence of any significant residual stone burden. At this point, then a retrograde pyelogram was performed through the scope. There did not appear to be any evidence of extravasation nor residual stone burden. The ureter was then examined as the ureteral scope was withdrawn. A 6 x 26 double-J stent was then placed into the right renal pelvis in a retrograde fashion under fluoroscopic guidance. The bladder was drained. The cystoscope was withdrawn. Please note, there was 1 stone fragment, which was retained, which will be sent for analysis. The patient tolerated the procedure well and was taken to the recovery room postoperatively. We will arrange for patient be discharged home with prescriptions for ciprofloxacin, Norco, and Ditropan. Mid-
level follow up in 1 week with KUB.

Medical Billing and Coding Forum

Ureteral Stent Removal

Posted on by
I have had a couple of the following scenario and not sure how I should code this, if it’s even billable.

The patient has a Cystoscopy with Holmium laser and stent placement. The patient comes to the office about a week later and has the stent removed by a LNP. The nurse documents to follow up with the doctor in a week. The office wants to bill 50384.

I don’t think this would be billable at all with this code, I would think that it would be a nurse visit if anything.

Any input would be helpful..

Thanks

Medical Billing and Coding Forum

Left ureteral implantation w/ closure of vesicostomy

Posted on by
Please help with this one. I work coding denials for multispecialty practice and need some help with urology. This is a pediatric patient. This procedure was for closure of a vesicostomy and left ureteral implantation. The initial coder coded this procedure with 50780 and 51880-51 and the 51880-51 was denied as incidental. 51880 is a "separate procedure", so I know it either gets billed alone or with a 59 mod if reported with an unrelated procedure. My question is basically is the 50780 truly an unrelated procedure from the 51880 or should the 50780 encompass the whole procedure. There is no CCI edit between the two. Here’s the note:

PREOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.

POSTOPERATIVE DIAGNOSIS:
1. Neurogenic bladder with vesicostomy.
2. Left grade 4 vesicoureteral reflux.

PROCEDURE:
1. Closure of vesicostomy
2. Left ureteral reimplantation.

INDICATIONS:
Patient is a 13-year-old boy with low level myelomeningocele with resulting bowel and bladder dysfunction. He has been managed with vesicostomy due to his unwillingness to perform intermittent catheterization. He is now performing intermittent cath and would like closure of the vesicostomy. There is also grade 4 left reflux which persists despite previous Deflux injection.

FINDINGS:
Vesicostomy with evidence of chronic bladder inflammation. Deflux injection sites noted around left orifice with significant fibrosis.

DESCRIPTION OF PROCEDURE:
After adequate general anesthesia was obtained, the patient was placed in a supine position and the external genitalia and lower abdomen were prepped and draped in usual sterile fashion. A 12-French Foley catheter was inserted in the vesicostomy site and the balloon inflated. A transverse incision was then made encompassing the vesicostomy site and carried down to the rectus fascia. This was opened transversely and elevated in the fashion of a Pfannenstiel incision. The vesicostomy site was secured with 2 sutures of 3-0 silk and dissected free from the rectus muscles. The bladder was then opened in the midline. The mucosa was noted to be mildly inflamed throughout. The Bookwalter retractor was then brought onto the field and placed in such a manner as to allow adequate visualization of the bladder interior. Despite this, however, there was exceptional difficulty seeing the area of the trigone due to superior location of the vesicostomy incision. For this reason the rectus fascia was then divided in the midline inferiorly to allow further separation of the muscle and better visualization of the base of the bladder. The left ureteral orifice was identified and cannulated with a 5-French feeding tube without difficulty. The right ureteral orifice was also identified. Dissection was then performed to free the left ureter from the surrounding detrusor. There was exceptional fibrotic reaction, however, and this intravesical dissection was unsuccessful. The ureter was entered during the dissection and I made the decision to perform extravesical dissection. The Bookwalter was rearranged to allow visualization of the left perivesical space. Dissection was commenced and it was noted that there was a very large amount of hard stool throughout the colon. This filled the pelvis and made dissection more difficult. The left vas deferens was identified and protected. Because of the difficulty in dissection I asked Dr. Chandler, pediatric surgeon, to come in and assist. We were then able to free the ureter from the surrounding detrusor muscle up to the pelvic brim. During this dissection the Deflux mounds were encountered and removed. Adequate length was then gained for ureteral reimplantation. The ureter was brought in through the posterior aspect of the bladder and a submucosal tunnel created in a Politano-Leadbetter fashion. The ureter was secured in its new location with interrupted 4-0 Vicryl suture. The defect where the left ureter was originally located was significant due to the degree of fibrosis. This was closed with running 2-0 Vicryl suture. The bladder was then closed with 2 layers, the first layer of 2-0 Vicryl followed by a second layer of 3-0 Vicryl. Prior to this, clear efflux was seen from both the right and left ureteral orifices. An 18-French Foley catheter was then brought out through the right side of the abdomen and secured with 3-0 nylon suture. The rectus fascia was closed with running 2-0 Vicryl. The wound then closed in layers with 3-0 and 5-0 Vicryl. A 12-French Foley catheter was inserted per urethra with return of light pink urine. Irrigation of suprapubic catheter showed no significant bladder leak prior to closure of the fascia. The wound was infiltrated with 0.25% Sensorcaine and sterile dressing applied. The patient was awakened and transferred to the recovery room.

Thanks in advance for you help!

Medical Billing and Coding Forum

Bladder Tumor Resection and Ureteral Stent placement

Posted on by
Can someone please offer guidance?
My provider performed transurethral resection of bladder tumor that invaded the ureteric orifice. He inserted a stent to "facilitate drainage".
NCCI Edits bundle the two procedures together, is it appropriate to unbundle them in this scenario?

"The patient had a large, approximately 3-4 cm papillary bladder tumor on his right lateral wall, obscuring the identification of his right ureteral orifice. This was resected sequentially down to muscle. The right ureteral orifice was identified and it was not the source of the tumor, but did appear to have some involvement of papillary tumor at the orifice. The right ureteral orifice was resected and sent as a separate pathologic specimen. Given the resection, we placed a ureteral stent on this side to facilitate drainage and also assist future resections."

52332-59-RT
52335

Thanks in advance…

Medical Billing and Coding Forum