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CPC sample question # 8


Preoperative Diagnosis: Status post left ureterolithotomy.

Postoperative Diagnosis: Status post ureterolithotomy; calculus of right renal pelvis.

Operative technique: The patient was brought to the cystoscopy suite on an outpatient basis status post left ureterolithotomy (6 hours ago) with an indwelling double J ureteral stent placed during surgery. She was brought in for stent removal. Patient was placed in the dorsal lithotomy position, prepped, and draped in the usual sterile fashion. The 21 scope was introduced with cystoscopy findings grossly normal. There was some obvious edema around the orifice of the stent. The stent was grasped with alligator biopsy forceps and removed without difficulty. She tolerated the procedure well. Surgeon will attempt to alkalinize the patient’s urine to dissolve the stone in her right pelvis, which has remained asymptomatic.

a. 52310
b. 52315
c. 52310-58
d. 52290      

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