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.

Procedure route

Fictional adult undergoes left ureteroscopy for a documented left ureteral calculus. The clinician passes the instruments through the urethra and bladder into the left ureter. No right-sided procedure is performed. The complete operative report identifies the stone-treatment method for book selection.

Device sequence

A temporary ureteral catheter is introduced during the procedure to support the endoscopic work. At completion, the catheter is removed. The clinician explicitly records that no self-retaining indwelling ureteral stent is left in place.

Completion record

The left-sided endoscopic treatment is completed at one encounter. The report does not document another independently necessary ureteral catheter procedure. The learner must distinguish temporary operative device use from a separately supported indwelling device placement.

Coding issue

An imported charge label says stent insertion despite the operative statement that the temporary catheter was removed. Use the actual procedure and final device status to review the charge. Do not let a generic device label override the signed operative record.

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 documented route reaches the left ureter through the urethra and bladder.
The temporary catheter is removed; no indwelling ureteral stent remains.
NCCI C.20 does not permit reporting this temporary use as the described indwelling-stent insertion.
Select the actual completed treatment from the full entry and its combinations; a charge label cannot supply a service the report excludes.

Reference sections: C.20

Practice the linked chart questions