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Urinary Tract Cards Flashcards

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1
Q

Adrenal Gland

A

1.PB.^^ ~ adrenal gland

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2
Q

Renal Pelvis

A

1.PE.^^ ~ renal pelvis

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3
Q

Bladder Neck

A

1.PL.^^ ~ bladder neck

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4
Q

Urethra

A

1.PQ.^^ ~ urethra

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5
Q

Urinary System NEC

A

1.PZ.^^ ~ urinary system NEC

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6
Q

Kidney

A

1.PC.^^ ~ kidney

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7
Q

Ureter

A

1.PG.^^ ~ ureter

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8
Q

Bladder

A

1.PM.^^ ~ bladder

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9
Q

Surgically constructed sites in urinary tract

A

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

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10
Q

Urolithiasis

A

N20-N22

Do not assign N23, mutually exclusive dx

If final dx irenal colic but diagnostic evidence confirms stones then CODE TO SITE OF STONES

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11
Q

Urolithiasis leading to hydronephrosis

A

N13.2~ hydronephrosis with renal and ureteral calculus obstruction

Additional code from N20—N23 to identify the site of the calculus may be assigned, optionally, diagnosis type 3/0ther problem,

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12
Q

Renal Colic

A

N23
##footnote
only with no evidence of stones during diagnostic testing

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13
Q

DI Studies for Urolithiasis

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

Classify urinary calculus to site of stone at time of presentation

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14
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
##footnote
When a destruction procedure is followed by extraction of remaining fragments two codes are required, one for destruction and one for extraction

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15
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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16
Q

Lithotripsy:

A

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

Procedure where calculi are fragmented by the use of a crushing device (lithotriptor)

Intracorporeal lithotripsy – use ultrasound, pneumatic, laser or electrohydraulic probes via endoscopy

Litholapaxy/lithopaxy = lithotripsy followed by irrigation

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17
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

Similar to bladder stones

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18
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)

“Minimally invasive method of managing renal and ureteral calculi

Uses sound waves (shock waves) to fragment stone “

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19
Q

Ureteral Stent - CCI

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

“May be inserted prior to destruction/extraction

  • Assist in identification of ureters and allow for passage of stone fragments”
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20
Q

Pt returns for stent removal - ICD

A

Z45.8 ~ Adjustment and management of other implanted devices

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21
Q

Extraction of calculi from kidney

A

1.PE.57.^^ ~ extraction renal pelvis
Includes stones from ureteropelvic junction

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22
Q

Percutaneous nephrolithotomy

A

1.PE.57.DT^^ ~ extraction renal pelvis, endoscopic approach with calculi/stone extraction

Code destruction same method as described previous - 1.PE.59.^^

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23
Q

Upper UTIs

A

Consists of Kidneys & Ureters

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24
Q

Acute pyelonephritis (pyelitis)

A

N10 ~ acute tubulo-intestinal nephritis
+
Use additional code (B95-B97) to identify infectious agent. (dx type 3/OP)
- E- Coli most common cause

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25
Chronic pyelonephritis
N11.^ Fourth digit identifies the underlying cause Pyelonephritis due to obstruction by calculus classify to urolithiasis
26
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
27
Acute Cytitis (bladder infection)
N30.0 plus additional code to identify causative organism E Coli most common
28
patient has a positive urine culture and the physician documents UTI (if no other more specific documentation is available)
– N39.0
29
Infection due to urinary catheterization
T83.5 ~ Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system. + Y84.6 ~ urinary catheterization
30
Non-infectious inflammatory conditions of bladder
"Interstitial cystitis Urethrotrigonitis Irradiation cystitis"
31
ambulatory care for cystoscopy
2.PM.70.BA ~ inspection bladder When the diagnosis describes an underlying condition (i.e. urethral stricture) assign code for underlying condition as Main or MRDx
32
Urethral stricture - Treatment
Dilated via meatotomy/urethrotomy 1.PQ.50.^^ ~ dilation urethra Do not assign if done solely to permit cystoscopy
33
Acute kidney injury (AKI) - formerly acute renal failure
N17.^ ~ acute renal failure "Abrupt or rapid decline in renal filtration Three categories: - Prerenal - Intrinsic - Postrenal " Lead: injury Secondary: Acute
34
Chronic Kidney Disease
N18.^ ~ chronic kidney disease "Formerly called chronic renal failure Presence of kidney damage for > 3 months - Irreversible - Initiated by other conditions – chronic glomerulonephritis (most frequent cause), diabetes, hypertension, nephrosclerosis, SLE, etc. " Lead: Failure Secondary: renal chronic
35
Extensive CKD
"Extensive CKD – dialysis required = STAGE 5 = end-stage kidney disease (ESKD)"
36
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 "Acute kidney disease occurring in CKD represents separate disease processes AoCKD – Acute on Chronic kidney disease"
37
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 Progressive nephropathy leading to ESKD common complication of diabetes mellitus
38
Type 1 diabetes with stage 1 chronic kidney disease
E10.20+ M N08.31* 3
39
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 Kidney disease can cause disease elsewhere
40
Dialysis
Hemodialysis & Peritoneal Assign Z49.1 or Z49.2 (MP) – visiting outpatient clinic for dialysis only plus an additional code for kidney disease (OP)
41
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
42
Hemodialysis and peritoneal dialysis require insertion of an access device
Z49.0 ~ preparatory care for dialysis
43
Hemodialysis
Hemodialysis - 1.PZ.21.^^
44
External arteriovenous shunt (AV shunt)
1.KY.76.LA-SJ ~ bypass artery with vein (short-term use)
45
Internal arteriovenous shunt
1.KY.76.LA ~ bypass artery with vein using arteriovenous fistula (long term use)
46
Peritoneal dialysis
Peritoneal: 1.PZ.21.HP-D4
47
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
48
Bladder Malignancy
Diagnosis is established by cystoscopy and biopsy 2.PM.71.BA ~ biopsy bladder using endoscopic per orifice approach Be careful when searching the alphabetical index for transitional cell carcinoma. If your search leads you to carcinoma in situ, you are not under the correct lead term of carcinoma. "90 % transitional cell carcinoma 10% squamous cell + few adenocarcinoma"
49
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
50
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
51
Cysview
3.PM.10.XK – Xray bladder following retrograde injection of contrast using special light soure Mandatory to assign in Ambulatory care or NACRS "Is a solution that may be instilled into the bladder prior to cystoscopy Gives a blue light which illuminates the cancer cells "
52
Intravesical Chemotherapy
EG: Thiotepa or BCG Classify to: 1.PM.35.^^ ~ pharmacotherapy local bladder (mandatory) *** Thiotepa = alkylating agent *** BCG = immunostimulant Variety of chemotherapeutic agents used as adjuvant therapy for bladder cancer to prevent recurrence or progression of disease
53
External Radiation Therapy - bladder
1.PM.27.JA ~ radiation bladder Performed for inoperable muscle-invasive bladder cancer or as adjuvant therapy pre surgical removal of diseased tissue
54
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
55
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 May require a form of urinary diversion
56
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) Continent urinary diversion – creation of a new bladder (neobladder)
57
Bladder Malignancy - Interventions
"Treatment depends on grade/stage and location of tumor Grading – degree of cellular differentiation Grade 1 – well differentiated Grade IV – anaplastic Staging – degree of local invasion and presence/absence of metastases"
58
AKI
Acute kidney injury
59
CAPD
Continuous ambulatory peritoneal dialysis
60
CKD
Chronic kidney disease
61
ESKD
End stage kidney disease
62
ESWL
Extracorporeal shock wave lithotripsy
63
GFR
Glomerular filtration rate
64
IVP
Intravenous pyelography
65
TUR
Transurethral resection
66
UTI
Urinary tract infection
Coding
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