0T768DZ
Dilation Ureter, Right to No Qualifier with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | T Urinary System |
| Operation | 7 Dilation |
| Body Part | 6 Ureter, Right |
| Approach | 8 Via Natural or Artificial Opening Endoscopic |
| Device | D Intraluminal Device |
| Qualifier | Z No Qualifier |
Operation Definition
Expanding an orifice or the lumen of a tubular body part
Procedure Overview
Dilation procedures widen a narrowed segment of the urinary tract, most often the ureter, urethra, or bladder neck, to restore normal urine flow through the existing channel. Balloon dilation of a ureteral stricture or urethral dilation for a post-surgical narrowing are typical examples, frequently performed under cystoscopic or fluoroscopic guidance.
Strictures develop from prior surgery, radiation, chronic catheterization, trauma, or scarring, and if left untreated can cause pain, recurrent infection, or kidney injury from obstructed drainage. Dilation offers a less invasive alternative to reconstructive surgery, though some strictures recur and require repeat treatment or an eventual bypass or repair.
Anatomy & Axis Detail
Ureter, Right
The right ureter can develop strictures from prior stone passage, surgical injury, radiation, or malignancy, and dilation is used to restore its caliber when narrowing impedes urinary drainage. A guidewire is passed retrograde through a cystoscope and up the ureter, over which balloon or coaxial dilators are advanced to stretch the stenotic segment, typically followed by stent placement to maintain the newly opened lumen. Because the right ureter crosses beneath the gonadal vessels and near the appendix, prior abdominal or pelvic surgery on that side is a common contributor to acquired strictures requiring this intervention. Coders should note that dilation addresses the narrowed lumen itself and is distinct from destruction of tissue causing obstruction, and that repeat dilations are common when strictures are fibrotic and prone to recurrence.
Approach: Via Natural or Artificial Opening Endoscopic
Via Natural or Artificial Opening Endoscopic describes instrumentation introduced through a natural orifice or a surgically created opening while using an endoscope for visualization, as in a routine colonoscopy performed through the anus. It differs from the plain Via Natural or Artificial Opening value by the added scope, and from Percutaneous Endoscopic by using an existing passage rather than a new skin puncture.
Device: Intraluminal Device
Intraluminal Device denotes a single device, such as a stent or occlusion device, positioned within the lumen of a tubular body part like a vessel, duct, or airway to maintain patency or occlude flow. It carries no drug coating or radioactivity, distinguishing it from the drug-eluting, radioactive, and bioactive intraluminal device values, and from Extraluminal Device, which sits outside rather than inside the lumen.
Coding & Documentation
Coding depends on confirming that the procedure expanded an existing orifice or lumen without creating a new passage or removing tissue; the device value also matters, since a stent or balloon left temporarily in place changes the code. Documentation should specify the exact site dilated, as ureteral, urethral, and bladder-neck dilations use different body part values. A common mistake is coding Dilation when a stricture was actually incised (Division) or excised, rather than mechanically stretched, or overlooking that an intraluminal device was left behind.