Question

htve mary le Gmitel and Endocrine Systems 376 CHAPTER 10 OPERATIVE NOTE The ws prepped and draped n the lithotomy position, giver venousl sedation, and the urethra was anesthetized with 2% Xvlocaine generally The patient was cystoscoped The urethra was normal, There was no evidence of bladder neoplasia. Uretaric orifices and ureters were fairly lateral bur appeared normal in shape and size Bilateral retrograde pyelogram was gerformed, which showed normal collecting system on the left-hand side. The right system was indeed hydronephrotic, he m pvidence of filling defect or calculi was identified. The system draines well an fluoroscopic images. I wonder if she may have had mid rot at a younger age because of this appearance. At any rate, there wasne evidence of inflammation or neoplasia or other significant abnormait The patient tolerated the procedure well. She will be followed up in the clinic in 3 months' time. n the following case Dr Avile provided beth the cystoscopic and fuaroscapic examinaton of the bdhey The physician also eparts the hilateal retrograde pyelapram CASE 10-8 Operative Report, Cystoscopy LOCATION O nt Hospita PATIENT Beth hilt SURGEON to A MO PREOPERATIVE DIAGNOSIS t Right hdonephs 2 Hematura ST POSTOPERATIVE DIAGNOSIS PRE 1. Mild hvdronephrosis 2 No evidence of abstruction 3 Possibie ald vesicaureteral reflux SERVICE CODE(S): POS rete ICD-10-CM DX CODEIS): PROCEDURE PERFORMED Cystoscapy bilateral retrograde pyelogram gnder fuoroscopic control CLINICAL NOTE The patient is a 79-year-oid woman who presented with micrahematuria (blood seen with microscapel Ultrasound showed mild right bydronephrosis hetaz PROCE of the insertic of urete he pro rocedur Migrant stones originate in the kidney and pass out theng d in the bladier Cancer adder Stones ere are several tynes of the

Can you help me me code this case problem?

Answer 1

ICD-10-cm is a diagnostic code
Diagnosis:
Right hydronephrosis - N13.30
Hematuria - R31
Procedure codes:
CPT codes for endoscopy, cystoscopy, urethroscopy, procedures on the bladder should be coded with 52000
Bilateral retrograde pyelogram under fluoroscopic control
The bilateral procedure involves both sides of the ureters, so code 52005-50
Modifier 50 for the bilateral procedure.
Fluroscopic control 74420
use modifier 26 if radiologist interpretation is there in hospital settings for this procedure
This procedure is done in outpatient settings so use only 74420 without a modifier
Urologist performed use their own equipemnt in outpatient settings, they receive full cost for radiology guidance also.
Bilateral retrograde pyelogram under fluoroscopic control 52005-50, 74420