1. Code the CPT and ICD-9 Procedural Codes for the following Op Report.
DIAGNOSIS: Bladder outlet obstruction
OPERATION: Cystoscopy with transurethral incision of the prostate and transurethral resection of the prostate
INDICATIONS: This is a 61-year-old black male with a history of renal transplant. He had a history of bladder outlet obstruction symptoms prior to his transplant. He was in urinary retention and has been maintained on an indwelling Foley catheter.
DESCRIPTION OF PROCEDURE: The patient was taken to the Operating Room and placed supine on the operating table after undergoing spinal anesthesia without difficulty. He was placed in the dorsal lithotomy position and the area of his genitalia and perineum were prepped and draped in standard sterile fashion. The #21 French cystoscope with the 30-degree lens was then placed through the patient's urethra and into his bladder. It was noted upon entering his prostate that there was a minimal amount of prostatic tissue obstructing the neck. In the prostate the neo-ureterocystotomy was noted to be in the upper right side dome of the bladder. There was a stent present. The ureteral orifice was not patent. The left ureteral orifice was patent. There were no mucosal abnormalities seen in the bladder, however, there were several cellules. His bladder was trabeculated and there was a cellule. The cystoscope was withdrawn then and the bladder emptied. The Van Buren sounds were then used to calibrate the urethra to 28 French, then and #24 French resectoscope sheath was placed into the patient's bladder. The scope was placed thorough the sheath with a Collings knife attached. A transurethral incision of the prostate was then made, first on the patient's right side form just proximal to his right ureteral orifice to the level of the verumontanum. This was then repeated on the left side without difficulty. That accomplished and the resectoscope was removed and #24 French loop was then placed on the resectoscope and it was placed back into the bladder. The median lobe was then resected with very few bites taken. Then the patient's left lobe of the prostate was resected without difficulty. We then resected the patient's right lobe of the prostate. Approximately four grams of prostatic tissue were resected, the resectoscope was withdrawn and the Ellik was used to evacuate these chips from the bladder. The resectoscope sheath was withdrawn and a three way #22 French Foley catheter was placed into the bladder and started on continuous irrigation. The patient was taken out of the dorsal lithotomy position. He was then transferred to the stretcher and taken to the postoperative holding area in stable condition. There were no complications during the case, estimated blood loss was 50 cc.

2. DIAGNOSIS: 1. Primary adenocarcinoma descending colon 2. Hydronephrosis, bilateral
OPERATION: 1. Cystoscopy 2. Bilateral insertion of Double J stents
FINDINGS AT OPERATION: Endoscopic examination of the urinary bladder showed no significant abnormalities. Double-J stent insertion as accomplished bilaterally with minimal difficulty in the patient's left side.
PROCEDURE: With the patient in the lithotomy position and under satisfactory general anesthesia, the genitalia were prepped and draped in a routine sterile manner. The McCarthy panendoscope was inserted, and 24-cm, 6-French, silastic, Double J stents inserted bilaterally with ease. The patient was then sent to the recovery room in satisfactory condition.

3. A patient had a renal auto-transplantation extracorporeal surgery, re-implantation of a kidney, and a partial nephrectomy. How would you report this procedure?

4. Harry had a couple of stones in both kidneys. He was taken into the lithotripsy unit and placed on the lithotripsy table in a supine position with the induction of anesthesia. The stones were well visualized and the patient received a total of 3,500 shocks with a maximum power setting of 3.0. The treatment was successful. How would you report this procedure?

5. A 65-year-old male patient has an indwelling nephroureteral double-J stent tube replaced to treat a ureteral obstruction caused by a stricture from postoperative scarring. His stent tube is exchanged every two months to prevent occlusion in the stent, UTI, and loss of kidney function. Dr. Mott did this procedure via a transurethral approach under conscious sedation and provided the radiological supervision and interpretation. How would you report this procedure?

6. Dr. Blue provided interpretation and results for a needle electromyography for anal sphincter function. How would you report this service?

7. A 48-year-old patient with BPH has his prostate removed via a laser enucleation. During this procedure he also has a vasectomy. What code(s) would report this procedure?

8. How would you report a bilateral cadaver donor nephrectomy with cold preservation?

9. A patient is diagnosed with a bladder tumor. The physician performs a cystourethroscopy with fulguration and resects a 7 cm bladder tumor. Which CPT® code(s) would you use for this service?

10. A 46-year-old female with history of cervical carcinoma. She underwent placement of an ileal conduit, with subsequent development of left hydronephrosis. A retrograde ureteral catheter was recently placed. She returns today for catheter exchange. Patient was placed in the supine position. The ileal conduit was accessed. The existing catheter was removed over a guidewire and replaced with a similar 10 French 50 cm long locking pigtail catheter. Contrast was injected, confirming good position. IMPRESSION: Left retrograde ureteral catheter exchange via the ileal conduit.

11. 45-year-old male is going to donate his kidney to his son. Operating ports where placed in standard position and the scope was inserted. Dissection of the renal artery and vein was performed isolating the kidney. The kidney was suspended only by the renal artery and vein as well as the ureter. A stapler was used to divide the vein just above the aorta and three clips across the ureter, extracting the kidney. This was placed on ice and sent to the recipient room. The correct CPT code is:

12. A Urologist examines the urinary collecting system with a cystourethroscope and removes four bladder tumors by fulguration. Two tumors measured 1.5cm and the other two tumors measured 2.5 cm and 3.0 cm. What code(s) should be reported?

13. The patient presents with recurrent bladder outlet obstruction secondary to prostate enlargement and requires transurethral resection of the prostate (TURP). The patient previously had a TUIP 10 years ago. Code the TURP.

14. Patient presents for insertion of a draining tube due to a neurogenic bladder. The physician performs the procedure by making a small incision into the lower abdominal wall, then an open incision in the bladder for placement of the catheter for drainage. Code the procedure.

15. Excision of a urachal cyst and an incarcerated umbilical hernia repair were performed on a six-year-old male. Code the procedure.

16. The Urologist is asked by the general surgeon to place ureteral catheters for visualisation of ureters during a complicated bowel surgery. Cystoscopy is performed and ureteral catheters are inserted. The general surgeon removes the catheters at the end of the case. Code the procedure.

17. Code the CPT and ICD-9 CM Codes for the Op Report Below: DIAGNOSIS: 1. Hematuria. 2. Chronic Prostatitis. 3. Right ureteral stricture
NAME OF OPERATION: 1. Cystoscopy. 2. Bilateral Retrogrades. 3. Ureteroscopy ANESTHESIA: General HISTORY: Patient is a 69-year-old male with persistent microscopic hematuria.
PROCEDURE: After satisfactory general anesthesia was achieved, the patient was placed in the lithotomy position. A 21-French scope with a 30-degree lens was utilized. A survey of the bladder revealed some moderate hematuria and blood oozing from the enlarged median lobe of the prostate. The trigone area itself was elevated secondary to this enlargement. The right ureteral orifice was cannulated with a #8 cone-tipped catheter, and a retrograde was performed. This revealed a small distal ureteral stricture. Otherwise, no abnormalities were noted. Similarly, a left retrograde was obtained. No abnormality was noted. A ureteroscopy was performed to the level of the stricture on the right side using the #7 mini scope. This appeared to be a soft inflammatory stricture, as if there had been a small stone pass through there recently. Otherwise no abnormalities were noted. This was not balloon dilated. The bladder was drained, and he was awakened and transferred to the recovery room in stable condition.

18. Repeat nephrolithotomy

19. Endoscopy for resection of renal tumor through an established stoma –

20. The surgeon aspirates the cyst of the kidney with the use of a percutaneous needle –

21. Nephrolithotomy for removal of kidney stones

22. The surgeon performs a laparoscopic ablation of a renal cyst

23. A surgeon removes a cyst from a patient’s kidney. The cyst is congenital.
What are the correct CPT and ICD-9-CM codes?

24. A 32 year old patient with a left transnephric external capped ureteral stent presents for routine fluoroscopically guided replacement. The patient has a stricture of the ureter at the pelviureteric junction.What are the appropriate procedure and diagnosis codes for the encounter?

25. A 40 year old hospitalized patient is in need of a kidney transplant and is next on the transplant list. A man who matches the patient’s tissue type and is an organ donor, is involved in an MVA and is pronounced brain dead upon arrival to the hospital. A nephrectomy is performed on the individual from the MVA. What is the correct code for nephrectomy?

26. What is the procedure code for the percutaneous cryotherapy ablation of renal tumor?

27. A patient comes in for a removal of a calculus from the renal pelvis via renal endoscopy through an established nephrostomy. How should this be coded?

28. A patient had a renal auto-transplantation extracorporeal surgery, re-implantation of a kidney, and a partial nephrectomy. How would you report this procedure?

29. A 65-year-old male patient has an indwelling nephroureteral double-J stent tube replaced to treat a ureteral obstruction caused by a stricture from postoperative scarring. His stent tube is exchanged every two months to prevent occlusion in the stent, UTI, and loss of kidney function. Dr. Mott did this procedure via a transurethral approach under conscious sedation and provided the radiological supervision and interpretation. How would you report this procedure?

30. Ureteroureterostomy

31. Ureterectomy with repair of the bladder cuff –

32. A patient sustained a crushing injury to the pelvis and flank. An IVPshows leakage of dye from the right ureter. She is taken to the operating room for the suture repair of her damaged right ureter. What are the correct CPT codes?

33. A 16 year old male patient was diagnosed with urinary retention, urethral stenosis and vesical neck stenosis. The surgeon performed a meatotomy and dilation of the urethral stenosis with a urethral dilator under spinal anesthesia.

34. Closure of urethrostomy in a 54 year old man

35. A 48-year-old patient with BPH has his prostate removed via a laser enucleation. During this procedure he also has a vasectomy. What code(s) would report this procedure?

36. George has his prostate removed via transurethral resection using non contact laser coagulation. What is the most appropriate code?

37. A cystourethroscopy with internal urethrotomy was performed in an eight year old female. What is the correct CPT code?

38. A patient with congenital stricture of the left ureteropelvic junction presents for cystourethroscopic ureter dilation. What are the correct procedure and diagnosis codes?

39. Operative Note: Patient has a ureteral stricture. Performed a cystoscopy with ureteroscopy and laser treatment of the stricture.

40. Using calibrated electronic equipment, an uroflowmetry test is performed for urinary retention to measure how well the bladder empties and the storage capacity of the bladder.

41. A steroid injection for urethral stricture using a cystourethroscope

42. A 67-year-old patient underwent contact laser vaporization with transurethral resection of the prostate.

43. A patient underwent cystourethroscopy with laser fulguration of two baldder tumors, each approximately 2.7 cm in size.

44. A patient with back pain was diagnosed with right renal abscess. He underwent percutaneous abscess drainage under fluoroscopic guidance. A 5 French tube was left in place to gravity for external drainage. The proper CPT codes are:

45. A surgeon performs aspiration of renal cysts from both the kidneys of a patient under ultrasonic guidance. The aspirate was sent to pathology for evaluation.

46. A nine-year-old male with a history of urinary burning and misdirected urinary stream presents to the urologist.  A cystourethroscopy was performed without difficulty.  The examination revealed urinary reflux and inflammation of the urethra due to right meatal stenosis.  Select the CPT code(s) for this procedure.

47. Preoperative Diagnosis:  Status post left ureterolithotomy
Postoperative Diagnosis:  Status post left ureterolithotomy; calculus of right renal pelvis
Procedure:  The patient was brought to the cystoscopy suite on an outpatient basis status post left ureterolithotomy (42 days ago) with an indwelling double J ureteral stent placed during surgery.  She was brought here to get removal.  She was placed in the dorsal lithotomy position, prepped and draped in a sterile fashion.  The 21 scope was introduced with cystoscopy being grossly normal.  There was obviously edema around the orifice from the stent.  This was grasped with the alligator biopsy forceps and removed without difficulty.  She tolerated the procedure nicely.  I will attempt to alkalinize her urine in hopes of dissolving a rather large stone in her right renal pelvis, which has remained asymptomatic.  Select the CPT cod(s) for this procedure.

48. A 68-year-old male with urinary retention undergoes an "Open suprapubic cystostomy tube placement."

49. A patient with a previous radical prostatectomy now presents to the physician with contracture of the vesical neck.  The physician performs a dilation of the urethral stricture with a filiform.  Select the CPT code for this procedure.

50. A surgeon performs plastic repair to correct a postoperative angulation of the ureter.  Select the CPT.