Question

What is the appropriate urinary code and surgical code to report for this case study? CPT Coding

A 66-year-old male has mild to moderate prostatic obstruction that has responded insufficiently to watchful waiting and medical therapies, such as alpha blockers and 5-alpha reductase inhibitors. The patient seeks an alternative to more invasive surgical prostatic procedures.

Description of Procedure: Preservice may include positioning and prepping the patient and inserting lidocaine jelly; placing the red rubber catheter to completely drain the bladder; inserting the treatment catheter and Prostaprobe; positioning patient in the lateral decubitus position to perform transrectal sonography; measuring the patient’s prostate length and checking position of treatment catheter balloon; removing the ultrasound probe and securing and positioning the rectal sensor; repositioning the patient supine; connect- ing the Prostaprobe to the microwave machine; replacing the ultrasound probe with a suprapubic probe to monitor the Prostaprobe in the bladder (every 15 minutes); waiting for the urethral temperature to return to normal; and removing catheters and disconnecting probes from the machine and the patient.

Support your coding with an explanation.

Answer 1

Benign prostatic hyperplasia—also called BPH—is a condition in men in which the prostate gland is enlarged and not cancerous. Benign prostatic hyperplasia is also called benign prostatic hypertrophy or benign prostatic obstruction.

The prostate goes through two main growth periods as a man ages. The first occurs early in puberty, when the prostate doubles in size. The second phase of growth begins around age 25 and continues during most of a man’s life. Benign prostatic hyperplasia often occurs with the second growth phase.

As the prostate enlarges, the gland presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder. The narrowing of the urethra and urinary retention—the inability to empty the bladder completely—cause many of the problems associated with benign prostatic hyperplasia.

What is the prostate?

The prostate is a walnut-shaped gland that is part of the male reproductive system. The main function of the prostate is to make a fluid that goes into semen. Prostate fluid is essential for a man’s fertility. The gland surrounds the urethra at the neck of the bladder. The bladder neck is the area where the urethra joins the bladder. The bladder and urethra are parts of the lower urinary tract. The prostate has two or more lobes, or sections, enclosed by an outer layer of tissue, and it is in front of the rectum, just below the bladder. The urethra is the tube that carries urine from the bladder to the outside of the body. In men, the urethra also carries semen out through the penis.

Drawing of the side view of the male lower urinary tract, with labels pointing to the bladder, groin, penis, prostate, scrotum, and urethra.

The prostate is a walnut-shaped gland that is part of the male reproductive system.

What causes benign prostatic hyperplasia?

The cause of benign prostatic hyperplasia is not well understood; however, it occurs mainly in older men. Benign prostatic hyperplasia does not develop in men whose testicles were removed before puberty. For this reason, some researchers believe factors related to aging and the testicles may cause benign prostatic hyperplasia.

Throughout their lives, men produce testosterone, a male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in their blood decreases, which leaves a higher proportion of estrogen. Scientific studies have suggested that benign prostatic hyperplasia may occur because the higher proportion of estrogen within the prostate increases the activity of substances that promote prostate cell growth.

Another theory focuses on dihydrotestosterone (DHT), a male hormone that plays a role in prostate development and growth. Some research has indicated that even with a drop in blood testosterone levels, older men continue to produce and accumulate high levels of DHT in the prostate. This accumulation of DHT may encourage prostate cells to continue to grow. Scientists have noted that men who do not produce DHT do not develop benign prostatic hyperplasia.

How common is benign prostatic hyperplasia.

Benign prostatic hyperplasia is the most common prostate problem for men older than age 50. In 2010, as many as 14 million men in the United States had lower urinary tract symptoms suggestive of benign prostatic hyperplasia.1 Although benign prostatic hyperplasia rarely causes symptoms before age 40, the occurrence and symptoms increase with age. Benign prostatic hyperplasia affects about 50 percent of men between the ages of 51 and 60 and up to 90 percent of men older than

Who is more likely to develop benign prostatic hyperplasia.

Men with the following factors are more likely to develop benign prostatic hyperplasia:

age 40 years and older

family history of benign prostatic hyperplasia

medical conditions such as obesity, heart and circulatory disease, and type 2 diabetes

lack of physical exercise

erectile dysfunction

What are the symptoms of benign prostatic hyperplasia?

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia may include

urinary frequency—urination eight or more times a day

urinary urgency—the inability to delay urination

trouble starting a urine stream

a weak or an interrupted urine stream

dribbling at the end of urination

nocturia—frequent urination during periods of sleep

urinary retention

urinary incontinence—the accidental loss of urine

pain after ejaculation or during urination

urine that has an unusual color or smell

Symptoms of benign prostatic hyperplasia most often come from

a blocked urethra

a bladder that is overworked from trying to pass urine through the blockage

The size of the prostate does not always determine the severity of the blockage or symptoms. Some men with greatly enlarged prostates have little blockage and few symptoms, while other men who have minimally enlarged prostates have greater blockage and more symptoms. Less than half of all men with benign prostatic hyperplasia have lower urinary tract symptoms.

Sometimes men may not know they have a blockage until they cannot urinate. This condition, called acute urinary retention, can result from taking over-the-counter cold or allergy medications that contain decongestants, such as pseudoephedrine and oxymetazoline. A potential side effect of these medications may prevent the bladder neck from relaxing and releasing urine. Medications that contain antihistamines, such as diphenhydramine, can weaken the contraction of bladder muscles and cause urinary retention, difficulty urinating, and painful urination. When men have partial urethra blockage, urinary retention also can occur as a result of alcohol consumption, cold temperatures, or a long period of inactivity.