A temporary catheter removed during ureteroscopy

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-09-09 · Outpatient professional procedure; cited Medicare NCCI relationship

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Operative indication

Synthetic procedure record, September 9, 2026. An adult has a symptomatic left ureteral calculus. The clinician performs cystourethroscopy, then advances the ureteroscope into the left ureter. No right-sided procedure is performed.

Signed treatment note

The left ureteral stone is fragmented with a laser and the fragments are removed as part of the ureteroscopic treatment. A temporary ureteral catheter supports the operative work. It is removed before the procedure ends.

Final device status

The report explicitly states that no self-retaining indwelling ureteral stent remains. The completed service is left ureteroscopic lithotripsy, without another independently indicated catheterization procedure. The operative note records completion and follow-up instructions.

Device worksheet

An imported charge label lists indwelling-stent insertion. Compare it with the signed note and final device status. Under Medicare NCCI, do not replace that unsupported charge with another catheterization line for the same temporary use; check the complete treatment entry.

Your coding worksheet

Trace the route and side.
State what remains after the procedure.
Compare the charge label with the operative record.
Review the complete treatment entry before adding device services.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Compare with the worked explanation

The ureteroscope reaches the left ureter through the urethra and bladder; left ureteroscopic lithotripsy is completed.
The temporary catheter is removed before completion, and no indwelling ureteral stent remains.
NCCI C.20 includes that temporary catheter insertion and removal in the procedure. It does not support an indwelling-stent line or another catheterization line for the same temporary use.
Use the current entry for the actual completed lithotripsy and its instructions; a generic charge label cannot establish a device left in place.

Reference sections: C.20

Practice the linked chart questions