CLINICAL NOTE: This lady has a right ureteral stricture secondary to prior treatment for uterine sarcoma.
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CLINICAL NOTE: This lady has a right ureteral stricture secondary to prior

treatment for uterine

sarcoma. CT scan performed a few months ago showed some straining in the right hemipelvis, although

examination at that time failed to demonstrate anything that would be consistent with recurrent

tumor. She is scheduled for follow-up CT scan in this regard in 1 week.

The patient tells me she has had some nocturia and urgency incontinence recently. There has been no

dysuria or hematuria.

PROCEDURE: The patient was placed in the lithotomy position after IV sedation. She was prepped and

draped in the lithotomy position. The #21 French cystoscope was passed into the bladder, and urine

collected for culture. Inspection of the bladder demonstrated findings consistent with radiation

cystitis, which was previously diagnosed. There is no frank neoplasia. The right ureteral stent was

grasped and removed through the urethral meatus, and under fluoroscopic control the guidewire was

advanced up the stent and the stent exchanged for a #7 French 26-cm stent in the usual fashion.

The patient tolerated the procedure well. She will be discharged with ciprofloxacin. We will also

start Detrol LA 4 mg nightly to see if this helps; a renewal prescription for the next year has

been given. Stent change will be arranged in 3 months. Patient was sent home on ciprofloxacin.

CPT Code(s):

ICD-10-CM Code(s): _

Abstracting Questions:

1. Are the removal and insertion each reported separately?

2. What type of code is assigned to report the removal of the stent?

3. Why does the patient have the stent?

4. The problem with the stent is reported as a .

5. Why did the patient initially require a stent?

6. What complication developed from the treatment?

7. What category of code is assigned to report the radiation?

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