Laurie Posted Fri 28th of June, 2019 12:56:16 PM
Hi one of our doctors did the following procedure but the patient was out patient. and 50940 is an in patient only code. Is there a better code to use?
for assistance in identification of the left ureter as there was concern
for potential entrapment.
DESCRIPTION OF PROCEDURE
On June 5, , I was called intraoperatively into the OR with Dr.
Blank. On my arrival, the patient is intubated on the operating room
table with an open abdomen. After scrubbing into the procedure, I was
able to visualize through the posterior peritoneum the peristalsis of
the right ureter; however, the left ureter was not able to be
immediately visualized. Therefore, the posterior peritoneum was opened
with immediate identification of the ureter. I then performed
ureterolysis tracing the ureter distally to visualize the ureter lateral
and posterior to the area of the most lateral cuff suture. There was no
apparent injury to the ureter at this location. At this point, I turned
the procedure back over to Dr.blank for completion, the patient having
tolerated my portion without complication.
SuperCoder Answered Mon 01st of July, 2019 08:51:58 AM
If the ureterolysis was performed for surgical access, not a separate medically indicated procedure and as such would not be reimbursed separately. Code only the main procedure. In the above scenario it seems ureters were freed from adhesions to avoid from injury from the main procedure.
NOTE: Ureterolysis, the freeing of the ureter in the retroperitoneal space has been bundled into many urological and general surgical codes. The changes generally follow CPT coding guidelines. For example, the inclusion of ureterolysis, 50715, in most genitourinary procedures is in accordance with CPT guidelines that state lysing of adhesions, unless extensive, is included in the surgical approach. Feel free to ask for any further query.