AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Issue 3; Ask the Editor
Ureteral Stone Migrating into Bladder
A 51-year-old male with a history of nephrolithiasis presents due to severe right flank pain and nausea and vomiting. A CT scan was performed in the emergency department which showed two stones together in the proximal right ureter. The patient was admitted and a cystoscopy was performed and upon entering the bladder, there were two stones at the base of the bladder, which appeared to be the same size as those that had been in the ureter. The stones were removed. As the postoperative diagnosis, the physician listed, “Passed right ureteral stones,” but listed, “Removal of right bladder stones” as the procedure performed. What are the appropriate diagnosis and procedure code for ureteral stones that migrated to and were removed from the bladder? ...
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Article Overview
This case-based article discusses how to think about diagnosis and procedure coding when stones are initially identified in the ureter but are later found in the bladder and removed during a cystoscopy. It is aimed at coders and billing staff working with urology and emergency department records, and it focuses on the distinction between the presenting condition, operative findings, and documented procedure. The article centers on diagnosis and procedure selection guidance for this type of encounter.
Why This Topic Matters
Stone cases can involve changes in location between presentation, imaging, and surgery, making documentation interpretation important for accurate coding and record consistency.
What You Will Learn
- How to interpret a stone case when the documented location changes during the encounter.
- How diagnosis and procedure documentation relate in a migrated-stone scenario.
- How an operative note and postoperative diagnosis may differ in this type of case.
- What information in the chart supports coding relevance for the encounter.
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Urology practices
- Emergency department coding staff
Codes Discussed
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