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Urinary Tract Cards Flashcards

(67 cards)

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1
Q

Scenario

A

Code

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2
Q

Urological Intervntions locations and

A
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3
Q

Adrenal Gland

A

1.PB.^^ ~ adrenal gland

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4
Q

Renal Pelivs

A

1.PE.^^ ~ renal pelvis

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5
Q

Bladder Neck

A

1.PL.^^ ~ bladder neck

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6
Q

Urethra

A

1.PQ.^^ ~ urethra

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7
Q

Urinary System NEC

A

1.PZ.^^ ~ urinary system NEC

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8
Q

Kidney

A

1.PC.^^ ~ kidney

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9
Q

Ureter

A

1.PG.^^ ~ ureter

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10
Q

Bladder

A

1.PM.^^ ~ bladder

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11
Q

Surgically constructed sites in tract

A

1.PV.^^ ~ surgically constructed sites in urinary tract

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12
Q

Urolithiasis

A
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13
Q

Urolithiasis

A

Do not assign any code from N20-N22 with N23

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14
Q

Urolithiasis leading to hydronephrosis

A

N13.2~ hydronephrosis with renal and ureteral calculus obstruction

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15
Q

Renal Colic

A

N23

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16
Q

Interventions

A
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17
Q

DI Studies

A

3.PZ.20.VA ~ computerized tomography [CT] urinary system NEC without contrast

3.PS.10.VC ~ xray kidney with ureter and bladder following intravenous pyelography (IVP)

3.PC.30.DA ~ ultrasound kidney alone

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18
Q

Surgical interventions for Urolithiasis

A

Removal of stones classify to extraction, by site

Destruction of stones classify to destruction, by site
- Site being the location of the stone

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19
Q

Extraction of bladder calculi

A

Extracted by means of a cystoscopy with an extraction device (basket)
1.PM.57.BA-GX (U)

Cystolithotomy = open approach into bladder to access bladder stones

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20
Q

Lithotripsy:

A

Classify to:
1.PM.59.^^ ~ destruction bladder
Assign additional code for extraction of fragments

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21
Q

Extraction Ureteral Calculi

A

Lithotripsy (destruction) + extraction = 2 codes
1.PG.59.^^ ~ destruction ureter
1.PG.57.DA-GX ~ extraction ureter, using endoscopic (percutaneous){antegrade} approach and other device

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22
Q

Extracorporeal Shock-Wave Lithotripsy (ESWL)

A

Classify to:
1.PG.59.KQ-AP~ destruction ureter (ESWL)
1.PE.59.KQ-AP ~ destruction renal pelvis (ESWL)

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23
Q

Ureteral Stent

A

Intent is to dilate
- Look up – dilation or insertion ureter
- - 1.PE.50.^^

If the stents are removed at the end of surgery use a status attribute “I” to indicate intraoperative

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24
Q

Pt returns for stent removal

A

Z45.8 ~ Adjustment and management of other implanted devices

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25
Extraction of calculi from kidney
1.PE.57.^^ ~ extraction renal pelvis Includes stones from ureteropelvic junction
26
Percutaneous nephrolithotomy
1.PE.57.DT^^ ~ extraction renal pelvis, endoscopic approach with calculi/stone extraction Code destruction same method as described previous - 1.PE.59.^^
27
Upper UTIs
28
Upper Urinary tract consists of Kidneys & Ureters
29
Acute pyelonephritis (pyelitis)
N10 ~ acute tubulo-intestinal nephritis + Use additional code (B95-B97) to identify infectious agent. (dx type 3/OP) - E- Coli most common cause
30
Chronic pyelonephritis
N11.^ Fourth digit identifies the underlying cause
31
Common Procedures
32
C&P - Cytoscopy & retrograde pyelography
Retrograde Pyelogram – 3.PS.10.XJ ~ xray kidney, ureter and bladder No bladder – 3.PH.10.XJ ~ xray kidney with ureter Do not assign additional code for cystoscopy Mandatory to capture DAD & NACRS as it is performed in endoscopy or operating room
33
Lower UTI
34
Acute Cytitis (bladder infection)
N30.0 plus additional code to identify causative organism E Coli most common
35
patient has a positive urine culture and the physician documents UTI (if no other more specific documentation is available)
– N39.0
36
Infection due to urinary catherization
T83.5 ~ Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system. + Y84.6 ~ urinary catheterization
37
UTIs
38
Non-infectious inflammatory conditions of bladder
39
ambulatory care for cystoscopy
2.PM.70.BA ~ inspection bladder
40
Urethral stricture
Dilated via meatotomy/urethrotomy 1.PQ.50 ~ dilation urethra Do not assign if done solely to permit cystoscopy
41
Acute and Chronic Kidney Disease
42
Acute kidney injury (AKI) - formerly acute renal failure
N17.^ ~ acute renal failure
43
Chronic Kidney Disease
N18.^ ~ chronic kidney disease
44
Extensive CKD
45
Acute Kidney Disease with CKD
AKI in a patient with CKD N17.^ + N18.^ (or N08.3*) are assigned Note: N18.^ or N08.3* are mandatory to assign
46
Kidney Disease with DM
E10-E14 (4th character .2) + (5th character describing extent of renal disease) = dagger /asterisk convention Plus N08.3^* ~ glomerular disorders in diabetes mellitus
47
Type 1 diabetes with stage 1 chronic kidney disease
E10.20+ M N08.31* 3
48
Kidney Disease as Cause of Disease Elsewhere
Uremic neuropathy N18.5+ / G63.8* Anemia in chronic kidney disease N18.9+ ~ chronic kidney disease unspecified D63.8 ~ anemia in other chronic disease
49
Dialysis
Hemodialysis & Peritoneal Assign Z49.1 or Z49.2 (MP) – visiting outpatient clinic for dialysis only plus an additional code for kidney disease (OP)
50
patients admitted for other reasons and continue to have dialysis while in hospital
Assign Z49^ + code for CKD (dx type 1) for patients admitted for other reasons and continue to have dialysis while in hospital
51
Hemodialysis and peritoneal dialysis require insertion of an access device
Z49.0 ~ preparatory care for dialysis
52
Hemodialysis - 1.PZ.21.^^
53
External arteriovenous shunt (AV shunt)
1.KY.76.LA-SJ ~ bypass artery with vein (short-term use)
54
Internal arteriovenous shunt
1.KY.76.LA ~ bypass artery with vein using arteriovenous fistula (long term use)
55
Peritoneal: 1.PZ.21.HP-D4
56
Continuous Ambulatory Peritoneal Dialysis (CAPD) - most common form
Can be done by patient at home Admission for placement catheter – Z49.0 ~ preparatory care for dialysis 1.OT.53.HA (DA) -TS ~ implantation device abdominal cavity
57
Bladder Malignancy
58
Bladder Malignancy
Diagnosis is established by cystoscopy and biopsy 2.PM.71.BA ~ biopsy bladder using endoscopic per orifice approach
59
Bladder Malignancy - Interventions
60
Small, superficial tumors amenable to transurethral fulguration or laser ablation (YAG or Argon)
1.PM.59.^^ ~ destruction bladder 1.PM.59.BA-GX – fulguration using electric current 1.PM.59.BA-AG – laser When biopsy obtained may optionally assign code for biopsy
61
TUR or TURBT bladder tumor
1.PM.87.BA ~ excision partial bladder Typical to use resectoscope for excision Fulguration (destruction) may follow – do not assign separate code
62
Cysview
3.PM.10.XK – Xray bladder following retrograde injection of contrast using special light soure Mandatory to assign in Ambulatory care or NACRS
63
Intravesical Chemotherapy
EG: Thiotepa or BCG Classify to: 1.PM.35.^^ ~ pharmacotherapy local bladder (mandatory) *** Thiotepa = alkylating agent *** BCG = immunostimulant
64
External Radiation Therapy
1.PM.27.JA ~ radiation bladder
65
Cystectomy
Partial – local invasive cancer of bladder 1.PM.87.^^ ~ excision partial bladder Total Cystectomy – without removal of surrounding structures 1.PM.89.^^ ~ excision total bladder Radical Cystectomy – high grade or invasive bladder cancer Involves en bloc resection bladder and adjacent organs 1.PM.91.^^ ~ excision radical bladder
66
Total/Radical Cystectomy
Two types: Continent urinary diversion – urine collected and stored internally, patient controls excretion Noncontinent – external appliance collects urine Captured at qualifier at 1.PM.91.^^ ~ excision radical bladder
67
Urinary Diversion
May require creation of urinary conduit (noncontinent urinary diversion) using a segment of ileum to pass urine to external stoma (ileal conduit) Additional code for procurement of intestine 1.NK.58.LA-XX-G ~ procurement small intestine… Continent urinary diversion – creation of a new bladder (neobladder)

Coding (14 decks)

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