Description: Microscopic hematuria with lateral lobe obstruction, mild.
Preoperative Diagnosis: Microscopic hematuria.
Postoperative Diagnosis:
1) Microscopic hematuria with lateral lobe obstruction, mild.
2) Mild benign prostatic hyperplasia.
Procedure Performed: Flexible cystoscopy.
Procedure: The patient was placed in the supine position and sterilely prepped and draped in the usual fashion. After 2% lidocaine was instilled, the anterior urethra is normal. The prostatic urethra reveals mild lateral lobe obstruction. There are no bladder tumors noted.
Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

The correct CPT code for a flexible cystoscopy is 52000. The ICD-10-CM codes N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms) and N13.8 (Other obstructive and reflux uropathy) accurately reflect the postoperative diagnosis of mild benign prostatic hyperplasia and mild lateral lobe obstruction, which is a form of obstructive uropathy.

Description: Microscopic Hematuria with Lateral Lobe Obstruction, Mild