Ask Dr. Z

I'm not sure how to code this. Would it be unlisted, urinary, or intestinal section? "PE: Abdomen/Flank: Soft, non-tender, non-distended. Positive for bowel sounds. No palpable masses or flank tenderness. Well-healing incisional wound. Ileal conduit with clear urine. Stoma somewhat retracted but reddish mucosa visible. The skin may have pulled away from the bowel mucosa. She was experiencing continuous urinary leakage due to a large vesicovaginal fistula at the trigone of her bladder. Patient is now s/p an ileal conduit urinary diversion and closure of VVF defect with democusalized detrussor flaps and concomitant ventral hernia repair. She had revision of her stoma for stenosis, and the stoma unfortunately re-stenosed. Has been staying relatively open - dilated to 28 French today without issues. Patient instructed on how to use self-dilator and will continue to do this several times per week."