Q&A: Ureteral stent

Q: Can you please weigh in on urinary stent insertion? Our coding department states that a query is needed to determine if the urinary stent is for drainage or dilation. From my own clinical perspective, a urinary stent would typically be placed for dilation given that the urinary system is already a marvelous drainage system. The stent does allow urine to flow through the ureter around a kidney stone that is blocking urine flow; however, if a stone is too big, then a stent may be deployed to passively dilate the ureter to allow the urine to continue to flow. Therefore, I do not feel it is necessary to ask the urologist “did you place this stent for dilation or drainage?” Your thoughts would be greatly appreciated.

A: We teach CDI teams some initial fundamentals on PCS coding as stated below:

• Providers are not required to use root operation terminology. It is the responsibility of the coder to translate the intent of the procedure into the applicable PCS root operation, assuming there is sufficient documentation.
• The CDI specialist must work to ensure that procedural documentation clearly identifies the intent or objective of the procedure.
• Understanding the definitions of the root operations is required in order to meet this goal.

Below are the definitions per the ICD-10-PCS guidelines:

Dilation

Definition: Expanding an orifice or the lumen of a tubular body part

Explanation: The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part.

Drainage

Definition: Taking or letting out fluids and/or gases from a body part

Explanation: The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies In medical coding and healthcare documentation, the root operation of "dilation" and "drainage" are distinct terms used to describe different procedures related to the urinary system.

Let's clarify when each of these root operations is typically used:

Dilation (Medical Root Operation):

• Dilation refers to a medical procedure where a medical professional expands or widens a narrowed or obstructed passage or structure within the body. In the context of the urinary system, ureteral dilation may involve the use of specialized medical instruments or balloons to widen a narrowed or strictured ureter.
• Ureteral dilation may be performed to treat conditions like ureteral strictures (narrowing of the ureter), ureteral scarring, or other obstructions that impede the flow of urine from the kidney to the bladder.
• Ureteral dilation is aimed at physically enlarging the ureter to improve urine flow. This procedure may or may not involve the placement of a stent.

Drainage (Medical Root Operation):

• Drainage, in the context of medical coding and procedures, refers to the act of removing fluids or gases from a body part. Ureteral drainage involves the placement of a urinary stent (ureteral stent) to maintain or restore urine flow from the kidney to the bladder or to bypass an obstruction.
• Ureteral drainage is typically performed when there is a blockage, such as a kidney stone, tumor, or stricture, that is preventing urine from flowing freely through the ureter. The stent serves to maintain the drainage pathway and allow urine to pass from the kidney to the bladder.

In summary, the key distinction between the root operations of "dilation" and "drainage" for ureteral procedures is as follows:

• Dilation involves widening or enlarging a narrowed or obstructed ureter without necessarily placing a stent. It aims to improve the passage of urine by physically altering the ureter.
• Drainage involves the placement of a urinary stent (ureteral stent) to maintain or restore the flow of urine through the ureter when there is a blockage or obstruction. It focuses on bypassing the obstruction and facilitating urine drainage.

The choice between these procedures will depend on the specific clinical situation and the judgment of the medical professional, taking into consideration the underlying condition and the most appropriate intervention to address it.

I would refer to the Coding Clinics published in July 2017 and April 2015 as well. As you will see, they give examples of both scenarios. To code this properly, the coder must interpret the procedure performed as well as the intent. If the procedure and intent are not well documented within the record, the provider should be queried to further clarify the documentation. Again, the provider should not be queried to document using ICD-10-PCS root operations but to clarify the procedure and the intent of the procedure.

Editor's note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, CDI education specialist for ACDIS/HCPro, answered this question. Contact her at dwilk@acdis.org.