Cystoscopy (Diagnostic / Ureteral Stent Removal)
Flexible cystourethroscopy[ with removal of [right / left] ureteral stent]
[Gross hematuria / Microscopic hematuria / Bladder cancer surveillance / Lower urinary tract symptoms / Ureteral stent removal after [ureteroscopy / stone treatment]].
Informed consent was obtained after discussion of risks, including discomfort, bleeding, urinary tract infection, and urethral injury, as well as benefits and alternatives.
[***, MD/DO]
Topical: 2% lidocaine jelly per urethra
The urethra was [normal / ***]. [The prostatic urethra was [nonobstructing / obstructing with lateral lobe enlargement / obstructing with a median lobe].] The bladder mucosa was [normal without tumors, stones, or diverticula / ***], with [no / mild / moderate] trabeculation. Both ureteral orifices were in normal position[ with clear efflux]. [The [right / left] ureteral stent was seen at the ureteral orifice and removed intact.]
A time-out was completed confirming the patient and procedure. The patient was positioned [supine / in the dorsal lithotomy position], the genitalia were prepped with [povidone-iodine / chlorhexidine] and draped, and 2% lidocaine jelly was instilled into the urethra. A flexible cystoscope was advanced through the urethra into the bladder under direct vision. The bladder was filled with [normal saline / sterile water] and inspected systematically, including retroflexion to view the bladder neck. [The ureteral stent was grasped with flexible graspers and removed intact with the cystoscope.] The bladder was drained, and the cystoscope was removed.
None
[None / Urine for culture / Bladder washings for cytology]
None
The patient tolerated the procedure well. Return precautions for fever, inability to void, or heavy bleeding were reviewed. Follow-up [in [X] / for [cytology / CT urogram] results].
Epic SmartPhrase Version
PROCEDURE: Flexible cystourethroscopy[ with removal of [right / left] ureteral stent]
INDICATION: ***
CONSENT: Informed consent obtained after discussion of risks, including discomfort, bleeding, UTI, and urethral injury, benefits, and alternatives.
PERFORMED BY: ***, MD/DO
ANESTHESIA: Topical 2% lidocaine jelly
FINDINGS: Urethra [normal / ***]. [Prostatic urethra ***.] Bladder mucosa [normal without tumors, stones, or diverticula / ***], [no / mild / moderate] trabeculation. Ureteral orifices normal in position[ with clear efflux]. [*** ureteral stent seen and removed intact.]
PROCEDURE DETAILS:
Time-out completed. Prepped and draped. Lidocaine jelly instilled. Flexible cystoscope advanced into the bladder under direct vision. Bladder filled and inspected systematically, including retroflexion. [Stent grasped and removed intact.] Bladder drained, scope removed.
EBL: None
SPECIMENS: [None / Urine culture / Bladder washings for cytology]
COMPLICATIONS: None
POST-PROCEDURE PLAN: Tolerated well. Return precautions reviewed. Follow-up ***.
Signed: .ME, .MYDEGREE
.TODAYVariants
Cystoscopy, Retrograde Pyelogram, and Ureteral Stent Placement (Operating Room)
Under [general / spinal] anesthesia, the patient was placed in the dorsal lithotomy position, prepped, and draped, and a time-out was completed. A rigid cystoscope was passed into the bladder. The [right / left] ureteral orifice was cannulated with a [5 Fr open-ended] catheter, and a retrograde pyelogram[ using minimal low-pressure contrast because of suspected infection] showed [a filling defect / an obstruction] at the [ureteropelvic junction / proximal ureter / mid ureter / distal ureter] with [mild / moderate / severe] hydronephrosis. A guidewire was advanced to the renal pelvis under fluoroscopy. A [6 Fr x [X] cm] double-J ureteral stent was advanced over the wire, and the wire was removed. Fluoroscopy confirmed the proximal coil in the renal pelvis, and cystoscopy confirmed the distal coil in the bladder. [Urine was aspirated from the renal pelvis and sent for culture.] The bladder was drained, and the cystoscope was removed. [A Foley catheter was placed.]
Charting Tips
- Describe the bladder survey as complete, including the dome, trigone, lateral, anterior, and posterior walls, and the bladder neck on retroflexion, and state that both ureteral orifices were seen. A complete survey supports a negative hematuria evaluation.
- Cystoscopy does not evaluate the kidneys or ureters. For hematuria, record the AUA risk category and the upper tract imaging done or planned (renal ultrasound or CT urography), or why none is indicated.
- Use normal saline irrigation when bladder washings are sent for cytology. Sterile water lyses the cells.
- For stent removal, state that the stent was removed intact. A retained fragment needs imaging.
- For stent placement, record the side, stent diameter and length, and whether a string was left attached, and document the planned removal or exchange date. A forgotten stent can encrust and require more complex surgery.
- For an obstructing stone with infection, document fever, urine findings, and that decompression was the goal. Send renal pelvis urine for culture and keep contrast volume and pressure low. Definitive stone treatment is deferred until the infection has cleared.
Documentation & Reimbursement Considerations
- Primary service: Report Cystoscopy (Diagnostic / Ureteral Stent Removal) as the primary service when it is the definitive operation performed.
- Diagnostic cystoscopy (1.49 wRVU, 0-day global) is included in any therapeutic cystoscopic procedure on the same day and is not reported separately.
- Stent removal through the cystoscope with a grasper has its own code (2.74 wRVU, 0-day global). Removal by pulling an attached string, without cystoscopy, is not a cystoscopic procedure.
- Stent insertion has its own code (2.75 wRVU, 0-day global). When the surgeon interprets the retrograde pyelogram, document the findings as a separate interpretation, because imaging supervision and interpretation may be separately reportable.
- A same-day office visit is billable only when a separately identifiable evaluation is documented beyond the decision to perform the cystoscopy.