Reference no: EM133254741
What is the CPT code for the following questions?
1- The surgeon performed a cystoscopy with ureteroscopy for laser treatment of a stricture of the left ureteropelvic junction. What is the appropriate CPT code?
2- PREOPERATIVE DIAGNOSES:
1. Interstitial cystitis
2. Urethral stenosis
POSTOPERATIVE DIAGNOSES:
1. Interstitial cystitis
2. Urethral stenosis
OPERATIONS PERFORMED:
1. Cystoscopy
2. Urethral dilation
OPERATIVE FINDINGS: Urethra was tight at 26 French and dilated with 32 French. Bladder neck is normal. Ureteral orifice is normal size, shape, and position, effluxing clear bilaterally. Bladder mucosa is normal. Bladder capacity is 700 mL under anesthesia. There is moderate glomerulation consistent with interstitial cystitis. Residual urine was 150 mL.
INDICATIONS: A patient with severe symptoms.
DESCRIPTION OF OPERATION: The patient was brought to the cystoscopy suite and placed on the table in lithotomy position. The patient was prepped and draped in the usual sterile fashion. A 21 Olympus cystoscope was inserted, and the bladder was viewed with 12- and 70-degree lenses. Bladder was filled by gravity to capacity, emptied, and again cystoscopy was performed with findings as above. Urethra was then calibrated with 32 French and dilation performed. The patient was taken to the recovery room in stable condition.
3- DIAGNOSIS: History of ureteral stone (two cpt codes)
PROCEDURE: Extraction of double J ureteral stent and right ureteroscopy
The patient was prepped and draped and placed in dorsal lithotomy position. The lower abdomen and genitalia were prepped and draped in the usual sterile technique. A 10-French cystoscope was introduced into the urethra and advanced into the bladder. The right ureteral stent was identified and was removed using grasping forceps. The stent was exanimated and found to be intact. Next, a 6-French ureteroscope was introduced into the bladder and advanced into the right ureter. The ureteroscope was introduced all the way to the level of UP. There were no residual stones. The ureteroscope was removed. The bladder was emptied and cystoscope removed. The patient tolerated the procedure well.