AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2019 Issue 2; Ask the Editor
Reimplantation of Ureters with Insertion of Tubes
A patient, who is diagnosed with bilateral ureteral reflux, had surgical repair via Cohen transtrigonal bilateral ureteric reimplantation and ureteral neocystostomy. After opening the bladder, the surgeon inserted feeding tubes inside the left ureteral orifice, dissected the ureter free from its attachments and mobilized the ureter. The same thing was done to the right ureter. The ureters were tunneled transtrigonally, starting with the left one to the right side, then the right ureter going to the left side. Is the insertion of the feeding tubes inherent to the bilateral ureteric reimplantation, or are separate codes assigned for placement of the tubes? ...
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Article Overview
This article addresses a surgical coding question involving bilateral ureteral reimplantation for ureteral reflux and the use of feeding tubes during the operative repair. It is relevant to urology coders, auditors, and surgical coding staff who need to understand how the procedure is framed for coding purposes and what parts of the operative work are considered inherent to the main operation.
Why This Topic Matters
Urology operative reports often include supporting steps that must be evaluated for whether they represent separate billable services or are part of the primary surgical procedure. This article helps clarify the coding scope of a ureteral reimplantation case involving intraoperative tube placement.
What You Will Learn
- How this ureteral reimplantation scenario is presented from a coding perspective.
- How to think about supporting intraoperative steps in relation to the main surgical procedure.
- What type of coding question the article is intended to answer.
- How operative assistance materials are discussed in the context of surgical repair.
Who Should Read This
- Medical coders
- Urology coders
- Surgical auditors
- Compliance staff
- Revenue cycle professionals
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