When a patient presents with hydronephrosis for exchange of ureteral stent via cystoscopy two PCS codes would be reported. This would be coded as “removal” of the stent and then “dilation” for the insertion of the new stent. The objective of the procedure is to dilate the ureter and not change the device. AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Second Quarter 2016, Pages 27 & 28 have a perfect example of this procedure with explanation.
Root Operation Definitions:
—Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane.
—Taking out or off a device from a body part
—Expanding an orifice or the lumen of a tubular body part
Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P
References AHA Coding Clinic for ICD-10-CM/PCS, Fourth Quarter, Page: 111 AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, Second Quarter 2016, Pages 27 & 28
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