Two ureteral stones and a temporary catheter

Clinical indication

Fictional patient Sienna Brooks, age 43, has recurrent left flank discomfort attributed by the urologist to two left distal-ureter stones. Current imaging identifies those stones without hydronephrosis. No renal stone, urinary infection or stone on the right is documented. The urologist confirms calculus of the left ureter as the diagnosis and schedules ureteroscopic treatment after discussing the options.

Operative access

At the scheduled outpatient procedure, an independently reporting anesthesia professional provides general anesthesia. The urologist passes the cystoscope through the urethra, identifies the left ureteral orifice and advances a guidewire. A temporary ureteral catheter assists access. There is no separately necessary diagnostic bladder procedure or treatment of another organ.

Stone treatment

The ureteroscope reaches two stones in the same left distal ureter, measuring 5 mm and 4 mm. Laser lithotripsy fragments both stones during the same operative encounter. The operator confirms satisfactory treatment of that ureter. No stone is treated in the kidney or contralateral ureter. The record does not describe another distinct renal-system procedure.

Catheter and completion

The temporary catheter and guidewire are removed before the procedure ends. No self-retaining indwelling ureteral stent remains, and no later stent-removal plan is recorded. The completed note documents no complication. The physician gives routine follow-up instructions. There is no separate unrelated E/M service on the operative date.

Draft claim review

The charge list proposes two units of ureteroscopic lithotripsy because there were two stones, plus an indwelling-stent insertion entry because a catheter was used. Determine the supported service count, verify the diagnosis and distinguish temporary access from a retained stent. Use the licensed entry for the actual ureteroscopic treatment and verify any applicable anatomical modifier instructions.

Your coding worksheet

1. Identify the reason for this encounter and the supported diagnoses.
2. List the services actually completed and the applicable code sets.
3. Use your books to select final codes, units and any supported modifiers.
4. Sequence the diagnoses and explain the relevant instruction.
5. Review included work and any separate coverage question. Explain why the strongest alternative does not fit.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.