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Ureterotomy with exploration or drainage is a surgical procedure that involves making an incision in the ureter, which is the tube that carries urine from the kidney to the bladder. This procedure is typically performed to allow for direct access to the ureter for the purposes of exploration or drainage. The incision is strategically made in the abdomen, and the specific location—upper, middle, or lower ureter—is determined based on the clinical indications for the procedure. During the operation, the abdominal wall muscles are carefully divided, and the peritoneum, which is the lining of the abdominal cavity, is retracted to provide access to the ureter. Once the ureter is located, it is meticulously dissected away from surrounding tissues, including the serosa and periureteral fat, to ensure a clear view and access for the procedure. An incision is then made in the ureter itself to facilitate exploration for any underlying disease or abnormalities that may be present. To manage any fluid accumulation or to facilitate drainage, a soft Penrose drain or suction tube is inserted into the ureter. This allows for effective drainage and flushing of the ureter with an irrigation solution. After the necessary exploration and drainage have been completed, the drainage tube is left in place, and the incisions are carefully closed around the drain to promote healing and minimize complications.
© Copyright 2025 Coding Ahead. All rights reserved.
The ureterotomy with exploration or drainage procedure is indicated for various clinical scenarios where direct access to the ureter is necessary. The following conditions may warrant this surgical intervention:
The ureterotomy with exploration or drainage involves several critical procedural steps that ensure effective access and management of the ureter. The following outlines the detailed steps of the procedure:
Post-procedure care following a ureterotomy with exploration or drainage is essential for ensuring proper recovery and monitoring for potential complications. Patients are typically observed for any signs of infection or complications related to the drainage tube. The drainage tube may remain in place for a specified duration, allowing for continuous monitoring and management of urine flow. Follow-up imaging or assessments may be necessary to evaluate the success of the procedure and to ensure that any underlying issues have been adequately addressed. Patients may also receive instructions regarding activity restrictions and signs of complications to watch for during their recovery period.
| Short Descr | EXPLORATION OF URETER | Medium Descr | URTROTOMY W/EXPL/DRG SEPARATE PROCEDURE | Long Descr | Ureterotomy with exploration or drainage (separate procedure) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 112 - Other OR therapeutic procedures of urinary tract |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| Pre-1990 | Added | Code added. |