1. Scenario 1 PREOPERATIVE DIAGNOSIS
Chronic pyelonephritis.

POSTOPERATIVE DIAGNOSIS
Vesicoureteral reflux.

PRIMARY PROCEDURE
URETHROCYSTOGRAPHY.

BRIEF HISTORY
This 25-year-old male has had a history of long-standing urinary tract infections with multiple recurrences. Urine cultures were positive for Escherichia coli.

PROCEDURE
Consent forms were signed, and the patient was taken to the radiology procedure suite. He was placed on the combination table and adjusted to allow for the films to be centered at the level of the upper border of the pubic symphysis. He was given mild sedation, prepped, and draped. A catheter was inserted into the urinary meatus through the urethra into the bladder. The bladder was then distended with the contrast material until the patient felt the urge to micturate. Voiding was then recorded on videotape. Vesicoureteral reflux was noted. The patient tolerated the procedure well and was taken to a recovery room. After he was fully awake, he was advised to have the abnormality surgically corrected.

Hint: Code for radiological supervision and interpretation.

What is the ICD-10-CM Code and the CPT Code?