luisa Posted Tue 14th of March, 2017 07:56:04 AM
1. Cystoscopy via APV with bladder irrigation and urethral placement of Cyberwand for cystolitholapaxy
2. Cystoscopy with left retrograde ureterogram
3. Cystoscopy with left 4.8Fr X 24cm JJ stent
The 10-French Cystoscope was inserted per umbilical APV and it was snug at the skin junction. Once it passed the APV was normal. The large yellow stone was seen. A 14Fr sheath and dilator was inserted over a wire into the urethra. The Cyberwand was inserted and the stone ground with visualization via the cystoscope. The bladder was then inspected. There was no cystitis cystica, remaining stones or abnormal masses. There was a left ureteral orfice appeared normal but the right was not clearly seen. The left retrograde ureterogram was shot with 10cc and the collecting system was abnormal with 2 calyces seen and several branching infundibula. There was bifidi pelvis with minimal capapcity. An attempt was made to a pass flexible ureteroscope but it would not enter ureteral orifice. This was abandoned. A left JJ stent 4.8 X 26cm was passed under fluoroscopy. The bladder was emptied.
Hello Will you be assist me with CPT codes?
SuperCoder Answered Wed 15th of March, 2017 10:21:29 AM
Greetings from SuperCoder.com!
- Cystoscopy via APV with bladder irrigation and urethral placement of Cyberwand for cystolitholapaxy – You should report code 52317 (Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm)) or 52318 (….complicated or large (over 2.5 cm)) based on the size of the stone for which litholapaxy has been performed.
- Cystoscopy with left retrograde ureterogram – Simply report code 74420 (Urography, retrograde, with or without KUB) for retrograde pyelogram
- Cystoscopy with left 4.8Fr X 24cm JJ stent – For stent placement, report code 52332 (Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type))
Please feel free to write if you have any concern or questions.