Determine the ICD-10-PCS procedure code

PATIENT: HARRAN, BRENT
Date: 24 November 2018

Preop DX: Right ureteral obstruction secondary to coloncancer

Postop DX: Same
Operation:

1. Cystoscopy

2. Right retrograde pyelogram
3. Removal and replacement of double-J stent

Surgeon: Yarina Shah, MD

Anesthesia: General

HISTORY/INDICATIONS: This is a 28-year-old black male with ahistory of colon cancer and secondary right ureteral obstructionwho had a stent inserted a number of months ago. At this time, heis in the hospital and it is time for a stent change. Consequently,the patient presents for the procedure.

PROCEDURE: The patient was taken to the operating room and therehe was given general anesthetic, positioned in the dorsal lithotomyposition, the genitalia scrubbed and prepped with Betadine. Steriletowels and sheets were utilized to drape the patient in the usualfashion. A cystoscope was introduced into the bladder. The ureteralcatheter was identi?ed. It was grabbed and removed without anydif?culty. Subsequently, the cystoscope was reinserted into thebladder and the right ureteral ori?ce was identi?ed over a Pollackcatheter. A glide wire was inserted into the right collectingsystem. Some contrast was injected and a hydronephrotic right sidewas noted. Then, the wire was placed through the Pollack catheter.With the wire in position, over the wire a 7 French 26 cm double-Jstent was inserted. Excellent coiling was noted ?uoroscopically inthe kidney and distally with a cystoscope. The bladder was thendrained and again it was inspected prior to removal. There was noevidence of any tumors or lesions in the bladder. The stent was ingood position. The cystoscope was removed and the patient was takento the recovery room awake and in stable condition.