Today we're going to look at Chapter 4,
the Urinary System. We'll start with our
anatomy lesson. Remember FTRs for"facts to
remember". The kidneys are two organs
in the body. You see we're only
going to diagram one side (one kidney). There are
right and left kidneys. On the inside of the
kidney, you have different parts labeled in this diagram.
Coming from the kidney to the bladder is
the ureter. The bladder is there and then
what is not labeled (in this diagram) is the urethra, which
is the part of the body between the
bladder and the outside of the body. The
urine would go from the kidney, down
through the ureter into the bladder and
be stored until it is eliminated through
the urethra. I want us to look at the
code book. There are other ways to use
the code book other than the Index and
the Urinary System is a good system to look at for a different
technique. It's not as large as
some of the other systems. I think it's
fairly easy to navigate and we're also
going to watch the colors (from the code book) so you should
be able to see the red font color. The words in red (the main heading)
are the parts of the urinary system.
There's the kidney, the ureter, the
bladder, and on the next page, the
urethra. Under each one of these
body parts, there are procedures. Incision,
Excision, Repair, Manipulation and Other (Procedures).
You also might have a part of your
procedures called "Introduction", which is
pretty much of a catch-all when
it's used. The bladder has (the Introduction section) along with
Incision, Removal, Excision, Introduction.
Again, Introduction can be a lot of
different things so don't think of it as
it's just "introducing" something but a
catch-all really for a lot of things.
(Other procedures include) Urodynamics, Repair, Laparoscopy,
Endoscopy (which would be Cystoscopy,
Urethroscopy, Cystourethroscopy,
Transurethral Surgery and the Vesicle
Neck and Prostate. Remember how in the
Digestive System, we got to the Ovaries
through the abdominal cavity (which is) part of
the Digestive System and not the Female
(Genital) System. Similarly, the prostate is
included in the Urinary section because of its
proximity to the urethra. For part
of this podcast, I'm going to talk about
how I used the code book to find
something when I was unable to find it
in the index. So I'll come back to that a little
bit later. Also, you're going to see where
I continued to mark up my code book.
Here's the red color (indicating the main heading) for this part of the body, the
Kidney and then I'll take the blue (the next level or subheading which indicates) the
different procedures and I'll write beside
it what it is- Incision, Kidney. I do that
because on some pages, there's more than
one (procedure or body part). On this page, see Excision, Kidney; Renal
Transplantation- Kidney; Introduction-Kidney up
here (top of the next column). Remember it's those things, it's
a catch-all really for many procedures
and this particular one is "Removing and
Replacing a stent percutaneously", just
"Removing the stent percutaneously" and
then the same thing, only transurethrally (instead of percutaneously).
Then we come into a different
section and I talk about that. I make a
little note. No fluoroscopic guidance? See
Evaluation and Management code. So if
you're not using fluoroscopic guidance,
you're going to use a different set of
codes. Anyway back to my notations, I'm
still in the Kidney (section). You see how I have
everything marked. Here's my other
procedure where I get into some of those
things under Kidney (heading) and then at the
bottom of the page I get into Ureter (a separate heading). Now,
we're in a different part of the body
system and we're going to do Ureter,
Incision, Biopsy and I begin to do my
mark ups for the guidelines.
Okay so you see what I'm doing here. I've
circled my families like I have all
along. Then we get into the Bladder (a new heading) now.
Incision in the bladder. Removal of
the bladder. Removal "within" the
bladder, I should say. A lot of these
things over here we get into the
Urodynamics (new heading) so I'll be looking at these,
talking about them more than looking at
them because it simply saves so much
more time. We can go so much more quickly.
There is one, I believe it is your operative
report, we will be talking about that. We
refer to this group of codes here and
you see how the codes are differentiated by
the size of the tumor. Urethra (new heading) similarly has (procedures like)
Incision, Excision, Repair
Manipulation and Other procedures. I
take the time to show you that just to
remind you there's more than one way to
find a code. Sometimes it's easier to me
to use the code book than it is to use
the index. So we'll talk about that a bit
more. The trickiest part of the body
system, the Urinary System, is the terms. I
hope that you print out the slides. I
offer the PowerPoint as a PDF so that
you can just print it out and read it,
study it, memorize the terms for the
procedures because depending on the
term, it really helps you know what part
of the body system you're going to go to
and which procedure within that part of
the body system you're going to go to. So
here I have defined the differences
between a cystotomy, a cystostomy and
a cystoscopy. I won't take the time to
read those but I hope you do.
Here's the difference between a
cystoscopy and ureteroscopy.
Nephrostomy, again my images are taken
from Google images unless I tell you
otherwise. Fulguration is a procedure
to destroy and remove tissue, We have
one of our exercises talks about
fulguration. The various ways that stones
are treated- calculi are stones. You can
have kidney stones and I've heard of
bladder stones, not as common and you can
have bile duct stones. Remember we saw
those in our last chapter. So one of the
ways we treat calculi is through the use
of shock wave lithotripsy,
also called ESWL. I have information here
along with the laser lithotripsy and
while I'm thinking of it, the information
on these slides is fair game for an exam
so I expect you to not only know how to
find a code but understand the terms for
these procedures that you are looking
for. Here's another treatment for stones.
Percutaneous nephrolithotomy abbreviated
as PCNL and I tell you there what
that does, how it works. Here's the
difference between a nephrolithotomy and
a nephrolithotripsy. A
ureteroscopy, you will often hear that
word, is a procedure that the doctor
using the scope goes into the urinary
tract to get the stone and here are some
of these stone extractors that are used.
They are little baskets that are used that are
employed through the scope into the
bladder. They grab the stone and then the basket
collapses around the stone and the physician pulls
it back out. Obviously, the size of the
stone determines in large extent what
you're going to use. Here are the
stents. We hear often in this chapter
about ureteral stents. I have a picture here
showing you the stent starting up in the
kidney and then coming down the ureter
into the bladder. That stent is
keeping the ureter open in order for the
urine to flow from the kidney to the
bladder. A bladder diverticulum is an
out pouching in the bladder wall like (a patient) might
have intestinal diverticulum, a
little pouch in the wall. People
can be born with these or they can
acquire them and as I told you here on
the slide, in a gentleman, it is usually due
to an enlarged prostate but it can also
come from a urethral stricture, whether
scar tissue in the urethra from some
type of injury or a disease that affects
people. Ureterocutaneous
fistula, I remind you hear what a fistula
is and then a ureteral cutaneous fistula
is the fistula between, this abnormal
passage between the ureter and the skin.
"Uretero", obviously, looking at the
ureter and "cutaneous" referring
to the skin. Really your medical
terminology comes back into play when
you're looking at the the way these
words are built, these different terms
are built. If you still have your
medical terminology textbook and I hope you do, take
a few moments to really look again at
some of those prefixes and suffixes to
help you understand the meaning of a
word. Even if you have never seen the
word before, if you can break it into its
parts and know what what each part means,
you can often figure it out. Then I have
a urethral caruncle, which is also
called a urethral prolapse or
urethral polyp. This often happens
in women and postmenopausal women quite
often and it will actually fall out of
the urethra and sometimes blocks the
passage of urine. It can often be
treated just with medications but
sometimes it is surgically treated and
that's when we would be using a CPT code.
I won't spend a lot of time talking about
Urodynamics except to tell you that a
lot of procedures are the measurement
of the flow of urine, the different
pressures figuring out where is the
problem. But once you know where the
problem is, then you can decide what the
treatment is going to be. I do mention
the modifier -51 for physician use. If you
are doing several urodynamic procedures
that are separate from one another or in
combination depending on the way the
code description is written, you may be
able to code them separately and append
modifier -51 for your physician use, so
your physician can be paid for multiple
procedures being done on a given day.
If your physician is
providing only the professional
component, which is the supervision and
interpretation of your urodynamics,
you're going to use a modifier -26 for
physician services. Here I have the two
urodynamics that are commonly performed.
The cystometrogram, I am much more
familiar with than the other one, the
uroflowmetry.
Okay, let's look at our procedures for
this chapter. There're not very many. I
have the blank slide first so that you
can attempt to find it and then the next
slide I will give you the
codes. A cystoscopy, left ureteroscopy
with laser lithotripsy. So remember what
we just read. The cystoscope is going
into the bladder; the ureteroscope is
going from the bladder down into the
ureters. So there's two instruments there
but you're only going to code the one which is
the most distant, which would be the
ureter. Your laser lithotripsy is a
method of breaking up those stones. It
just falls under lithotripsy 52353.
Here's another one- cystoscopy with
insertion of a permanent urethral
stent. There's your code. Now I wanted
to bring to your attention in the code
book, read it carefully because there
are places where the descriptor is for a
temporary stent and this one is a
permanent one. So you want to make sure that
the code you're choosing has the
correct description. Here's a
cystoscopy with bladder biopsies and
fulguration, the Operative Report
#2. Exercise 4.30. You notice
when you read that operative report a
0.5 centimeter lesion was fulgurated.
When I went into the Index under cystourethroscopy
with fulguration, lesion
I go there and those codes did
not differentiate by the size of the
lesion. I went back to the Index, looked
again and I chose the term "tumor"
and when I go there, they are
differentiated by the size of the lesion.
So be sure when you go from your Index
to your code book to read your code
descriptors. Don't ever code from
the Index because of this very reason. It
can send you down the wrong path. Take
the code that's been given to you from
the Index, go to the code book, look it up and
read it. Does it fully describe the
situation you're trying to code? If it
doesn't, then either go back to the Index
or go to the code book itself, looking
under various body parts and the
procedures within those body parts to
try and find it a different way.
Exercise 4.31 #2 Under ultrasound
guidance, the physician
percutaneously inserts a ureteral stent.
This was a new access and no nephrostomy
catheter was needed. Now I know that
there are codes within the code book
that talk about a new access or using an
existing access but I couldn't remember
for the life of me where they were. So I
tell you here, I kind of walk you through
what I did. Initially I couldn't find a
code in the Index that referenced at all
this access, be it new access or pre-existing
so I went to the CPT codes for the
procedures under the Ureter and then
looked under the Introduction (section) because
remember, the Introduction section is
kind of a catch-all of many procedures
and I found in that section the
percutaneous insertion of the ureteral
stent. When I took that code and found it...
once I had my code, I went
back to the Index and thought, what or
how could I have looked this up
using the Index? I can get as far as the
Ureter, the stent and the placement, but
the code range that is there, the
descriptor in the Index is with
nephrostogram or ureterogram. Both of
those I think of as an x-ray procedure,
and not an ultrasound procedure. So
that's why I didn't go to either
one of those. So I think in the field I
would have just gone right to this
section of the code book and found it.
Let me show you what I'm talking about
so you can follow me in the code book.
When I say that I went to the Ureter, now we're in the Urethra.
Before that was the Bladder, before the
Bladder, keep going back until I get to
the Ureter. I'm in the Ureter and then I
was looking for Introduction.
There we go. So if you wanted to just
start at the very beginning, you would go
to where the word "Ureter" is written,
which is on the previous page, right here
at the bottom, the red color, is when it's
beginning, the section related to the
Ureters is beginning. Then I have my
notes there. So then I went to the part
called the "Introduction" because I know
it has a lot of things in it and sure
enough, when I started reading, it talks
about a percutaneous insertion of a
ureteral stent and when I go over and I
looked at my family of codes that I had
circled, this is where I remembered seeing it.
It's a little easier to see so here's
the family of codes I have circled.
Pre-existing, new access without separate
nephrostomy catheter and new access with
separate nephrostomy catheter. If you
remember on our slide it said "no
nephrostomy catheter was needed" so that
tells us that we are going to be "without
separate nephrostomy catheter" so you
might say, how did you know that was
there? Well again, if you're looking at
the body part, the Ureter is in red (indicating a main section) and
in the blue (indicating a subheading) you have the different
procedures on the Ureter. The first one
is Incision and Biopsy, Excision,
Introduction, which, as I said, is like a
catch-all, there's so many things in
Introduction. Then here's Repair, we're
still in the Ureter. There's your
Laparoscopy, your Endoscopy and that's it.
That's it for the procedures on the Ureter
so it has to be somewhere within
those six pages, just
another way to use your code book.
Closure of ureterocutaneous fistula
and it actually is in the Index under
"fistula" but I also was able to find it
under "Repair" in the Ureter section. Let
me take you back there (in the codebook). We're still back
in "Ureter" where we just were
looking only now we're under Repair.
Here's Repair so i will read the
guidelines and look here just read, and
Repair read, read, read, read Repair codes.
Keep reading and here it is.
Closure of ureterocutaneous
fistula. Ex. 4.31 #6 A cystoscopy with your ureteroscopy
for removal of ureteral stone.
There is your index path and
your code. Ex. 4.31 #8 Fulguration of a urethral caruncle.
Now when I had a little bit of trouble
with this one, so I just want to talk
about it. When I look at the Urethra
procedures in the code book. there is no
fulguration procedure. The closest thing
is an excision. Fulguration is the
destruction of tissue by that high
current. So if you're
looking for destruction and fulguration
is not there, the closest thing is
probably going to be excision. Sure enough
when you look there, there is an
entry for excision of a caruncle. It's
also found under the Urethra
as destruction of a lesion. So we have those
two paths there.
Ex 4.31 #8 Cystotomy with excision of a bladder
diverticulum. I defined that a little
earlier in this lecture. There's
your pathway and the code. Ok if you have
any questions about CPT codes within the
Urinary System you can post them in the
discussion board along with the index
path you use to try to find the code. I
will attempt to answer them. Thank you so
much and have a good evening.