Quick Coding with Medycoding
Scenario 1(Verified)
Diagnosis: Right Renal Calculus : N20.0
Obstructive Renal pelvic stone :N20.0
Malrotated Kidney: Q63.2
Procedure:
Cystourethroscopy with removal of right uteral stent +Right ureteroscopy and pyeloscopy with Laser lithotripsy-
Stone basketing and insertion of indwelling ureteral Stent: 52356-RT
Description:
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Dorsal Lithotomy Position
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Cystoscopy was inserted
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Graps the right stent and pull it through the meatus
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Ureteroscope Inserted
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Thulium laser was used to fracture the stone
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Stone was retrieved with basket
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A JJ Stone was passed without resistance.
Scenario 2 (Verified)
Diagnosis: Right Ureteral Calculus with hydronephrosis and renal colic : N13.2
Procedure: Cystoscopy with right ureteral stent placement : 52332-RT
Description:
Dorsal Lithotomy Position
Cystoscopy was inserted
Placed a 6 French *26 cm double J ureteral Stent.
Scenario 3 (Verified)
Diagnosis: Overactive Bladder : N32.81
Other Chronic Cystitis without Hematuria : N30.20
Benign Prostate Hyperplasia with Obstruction : N40.1,N13.8
Bladder Trabeculation : N32.89
Gross Hematuria : R31.0
Procedure: Cystoscopy 52000
Description:
The patient was placed in the dorsal lithotomy position, and her genitalia were prepped and draped in a sterile fashion. The flexible cystoscope was inserted with the findings as below. The scope was removed, and the patient was taken to PACU in stable condition.
Scenario 4 (Verified)
Diagnosis: Bulbar Urethral stricture : N35.812 (Male)
Bladder Trabeculation : N32.89
Procedure: Cystourethroscopy with dilation of urethra 52281
Description: Lidocaine jelly was instilled in the uretra.
Dilated the distal urethra with Van buren sounds to to 24 French and then performed rigid cystoscopy.
I then used metal Hayman sounds to dilate the entire urethra from 16 French all the way through 34 French.
Scenario 5 (Verified)
Diagnosis: Flaccid Neuropathic bladder,not elsewhere classified : N31.2
Procedure: Medronics Sacral nerve stimulator Stage 1 (Placement of lead and space for neurostimulator) : 64561 Notes: InterStim Therapy is a type of sacral nerve stimulation procedure. Report CPT code 64561, Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement), for the initial encounter for the insertion of the test lead.
Description: Patient in the prone position Lumbar and sacral areas of the spinal column and sacrum were prepped and draped Under fluoroscopic control, placement of 20 French spinal needles was placed on either side of the midline through the S3 foramen. Needle stylet was removed, and replaced with the long metal trochar The skin was nicked, and the lead introducer was placed over the trochar into proper position as seen under fluoroscopy.The permanent lead was placed through it into the proper position. Right S3 Foramen A 2-3cm transverse mark was made at the lateral edge of the buttock 2 fingerbreadths below the iliac crest. Then incised sharply,and the generator pocket was sharply dissected subcutaneously circumferentially on the Right side. The lead was transferred through the subcutaneous tunnel into the pocket. Generator Pocket in right Buttock
Scenario 6 (Verified)
Diagnosis: Urinary Retention: R33.9
Hypotonic Bladder : N31.2
Procedure: Stage 2 Medtronic (Insertion of Neurostimulator): 64590
CPT Assistant, March 2024 Page: 11 Note: Initial programming for implanted neurostimulators occurs in the operating room (OR) during the insertion or revision of the neurostimulator. The programmer is used in the OR to check for impedance after neurostimulator insertion. Additional programming may occur following the insertion or revision of the neurostimulator within the 10-day global period. Because programming is included in codes 64590 and 64595, separate codes should not be reported for this service. Codes 95971 and 95972 should only be reported if additional programming occurs beyond the 10-day global period; however, the additional programming should include additional adjustments to the settings and not just checking impedance. As stated in the guidelines for these codes, simple programming includes the adjustment of one to three parameters, and complex programming includes the adjustment of more than three parameters. Electronic analysis to document settings and electrode impedances without programming may be reported with code 95970.
Description: Incision was then opened up in the same line as previously. I was very careful not to cut the lead. The pocket was opened, and I pulled out the connector. The lead was disconnected from the temporary extension electrode. The lead was dried off and inserted into a generator. The screw was tightened and the generator was placed into the pocket after the pocket was irrigated with antibiotic irrigation.
Scenario 7 (Verified)
Diagnosis: Prostate Cancer : C61
Procedure: Transrectal ultrasound, with prostate biopsy (TRUS) : 55700, 76872
Description: Initiated the procedure by performing a rectal exam which revealed a Small prostate without nodules or induration. The ultrasound probe was inserted into the rectum and The prostate was thoroughly visualized in the transverse and sagittal planes. Biopsy: Biopsy cores were taken.
Scenario 8 (Verified)
Diagnosis:
Urinary retention : R33.9
Urethral stricture : N35.919
Procedure: Urethroscopy with attempted dilation of urethra, removal and replacement of suprapubic tube: 52281-53
Description: Rigid cystoscopy was performed I then replaced the cystoscope with a visual internal urethrotome and used the cold knife to just open up that little pinpoint area. This led me into a large false passage where no true lumen was found. I attempted many times with a wire to try to find a true lumen into the bladder but was completely unsuccessful. I remove the suprapubic tube and placed a flexible cystoscope into the bladder that way. I attempted multiple times with a guidewire to get into the bladder neck but was unsuccessful as well. At this point I abandon further attempts and replace the suprapubic tube with a 22 French Foley
Scenario 9 (Verified)
Diagnosis: Recurrent bladder tumors D49.4
Personal history of malignant neoplasm of bladder
Urothelical Carcinoma of Bladder near Dome : C67.1
Procedure: Transurethral Resection of a bladder tumor- medium 52235
Description: 26 French resectoscope sheath was introduced in the bladder.
There were 2 adjacent papillary tumors near the dome.
The bipolar cutting loop electrode was used to resect them.
The circumference and base of the tumors were thoroughly fulgurated using electrocautery.
Scenario 10 (Verified)
Diagnosis: Calculus of kidney N20.0
Procedure: Left Extracorporeal Shockwave Lithotripsy 50590,LT
Description: placed in a supine position on the table of the Dornier Compact Delta lithotripsy machine Biplanar fluoroscopic imaging was used to align the stone in the XY and Z planes, and fluoroscopy was used throughout the procedure to keep the stone properly aligned. Shockwave treatments were started at a power setting of 1, and was gradually increased to 7 . A total of 2500 shocks were delivered.
Scenario 11 (Verified)
Diagnosis: Bladder Calculi N21.0
Procedure: Cystolitholapaxy, large 52318
Description: He was placed on dorsolithotomy position.
Rigid cystoscopy was performed with a 25 French cystoscope.
He had at least 3 of them that each 1 were 1 to 2 cm.
The holmium laser fiber was then used to fracture the stones into multiple pieces and the Urovac evacuator was used to remove the pieces.
Scenario 12 (Verified)
Diagnosis: BPH with lower urinary tract symptoms
Procedure: Cystoscopy, with insertion of Transprostatic implant 52441, 52442*3
Description: The UroLift cystoscope was introduced into the bladder under direct vision. We then equipped with the Urolift device and 4 tacks were delivered with 2 implants on the left, and 2 on the right. They were deployed approximately 1-1/2-2 cm from the bladder neck with the verumontanum being the distal landmark.
Scenario 13 (Verified)
Diagnosis: History of bladder cancer Z85.51
Chemotherapy : Z92.21
Radiation therapy History : Z92.3
Bladder Trabeculation N32.89
Procedure: Cystoscopy, selective cytologies, bilateral retrograde pyelograms, random bladder biopsies with fulguration 52005-59, 52204
Description: Rigid cystoscopy was performed. There was some nodular regrowth of the prostate but overall open. Radiopaque contrast was injected which revealed no filling defect hydronephrosis or other abnormalities. The contrast drained promptly. I repeated the same procedure on the right side. I then used a cold cup biopsy forcep to take random biopsy from the right lateral wall left lateral wall posterior wall dome and trigone..
Scenario 14 (Verified)
Diagnosis: Prostate Cancer C61
Procedure: HIFU 55880
Description: Ultrasound probe was then placed in the rectum image.
Position the prostate we treated with total energy of 7257J 69 cycle
Scenario 15 (Verified)
Diagnosis: BPH N40.0
Chronic Prosatitis N41.1
Procedure: Plasma button TURP 52601
Description: The median lobe was small but vaporized with the plasma button.
Scenario 16 (Verified)
Diagnosis: Right Hydroneprhosis
Procedure: Cystoscopy, right retrograde pyelogram, 52005-59
Right double J stent exchange 52332
Description: A 5 French open catheter was advanced over the sensor wire and contrast was adminstered, outlining a tortuous renal pelvis and proximal ureter with a loop. A double stent was passed over the wire
Scenario 17 (Verified)
Diagnosis: Elevated PSA
Procedure: Tranrectal Ultrasound , Tranrectal ultrasound Gudiance, MRI ultrasound Guided Prostate Biopsy Added 55700,F 76498,F-26 (MRI-TRUS fusion-guided prostate biopsy performed)
Scenario 18 (Verified)
Diagnosis: Invasive Ductal carcinoma of Right Breast 3 Oclock : C50.811
Procedure: Right Partial Mastectomy- 19301-RT
Injection of Radioactive tracer for identification of Sentinel Lymph node- 38792 (Radioactive tracer)
Right Sentinel Lymph node biopsy- 38525-RT
Scenario 19 (Verified)
Diagnosis:C50.912
Left breast wire guided partial Mastectomy 19301,LT
Left breast wire guided excisional biopsy through same incision