Here is a sample Nephroureteral Catheter Placement Report that medical coders may use for coding purposes:
Patient Name: John Doe
Date of Procedure: 04/10/2023
Procedure: Nephroureteral Catheter Placement
Procedure Description:
The patient was placed under general anesthesia and prepped and draped in the usual sterile fashion. A cystoscope was inserted through the urethra and advanced to the bladder. The ureteral orifices were identified, and a guidewire was passed through the right ureteral orifice and advanced to the level of the renal pelvis under fluoroscopic guidance. The cystoscope was removed, and a nephroureteral catheter was inserted over the guidewire and advanced to the level of the renal pelvis. The guidewire was removed, and the nephroureteral catheter was secured to the patient’s thigh with a sterile adhesive.
Findings:
The procedure was successful, and the nephroureteral catheter was in good position. No complications were noted during the procedure.
Impression:
Successful placement of a nephroureteral catheter for drainage of the right kidney.
Plan:
The patient will be monitored for any signs of complications, and the nephroureteral catheter will remain in place until further notice.
This report provides a clear description of the procedure, any findings or complications, and the plan for ongoing care. It is important for medical coders to use accurate and detailed documentation to ensure correct coding and billing for the procedure.