Practice Case 1 - {{Urology}}

Practice Cases

This practice case focuses on evaluation and management (E/M) and procedural coding for a complex urological patient. Use the clinical note below to determine the appropriate ICD-10-CM, CPT, and E/M codes.

Clinical Note: Subsequent Hospital Visit

Date: February 1, 2026
Patient: 72-year-old male
Chief Complaint: Worsening left flank pain and fever.

History of Present Illness:
Patient was admitted yesterday with known nephrolithiasis (8mm left proximal ureteral stone). Today, he reports escalating pain (10/10) despite IV morphine. He is now febrile (102.1°F) and tachycardic (HR 115).

Review of Systems/Physical Exam:

• Constitutional: Febrile, acutely distressed.

• Genitourinary: Severe left CVA tenderness; decreased urine output since admission.

• Labs: WBC increased from 11k to 19k. Creatinine rose from 1.2 to 2.6 (baseline 1.1). Lactate is 2.8.

• Imaging: Repeat CT shows worsening hydronephrosis and inflammatory changes around the left kidney.

Assessment & Plan:

1. Obstructive Uropathy with Sepsis: Patient has an obstructed, infected kidney (ureteral stone with systemic symptoms). This is a life-threatening condition.

2. Acute Kidney Injury: Rising creatinine secondary to obstruction.

3. Plan: Urgent cystourethroscopy with insertion of an indwelling JJ stent to bypass the obstruction and drain the infected collecting system. Urology has been consulted and will proceed immediately. IV antibiotics (Vancomycin/Zosyn) initiated.

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Coding Task

Identify the following based on the note above:

1. Primary Diagnosis (ICD-10-CM)

2. E/M Code (Subsequent Inpatient)

3. Procedure Code (CPT)

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Medical Keyword: Nephrolithiasis

Consistent with our Space guidelines, below is the breakdown of a key term found in this case:

• Short Definition: The presence of stones (calculi) within the kidney.[etymonline]​

• Long Definition: A condition where mineral and acid salts form hard deposits (calculi) inside the kidneys, often causing severe pain (renal colic), obstruction of the urinary tract, and potential infection.[en.wikipedia]​

• Etymology: Derived from the Greek nephro- (kidney) + lithos (stone) + -iasis (pathological condition or morbid state).etymonline+1

• Related Terms: Cystoscopy (kystis “bladder” + skopein “to look at”), Ureterolithiasis (stones in the ureter), and Hydronephrosis (swelling of the kidney due to urine backup).etymonline+1

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Answer Key & Rationale

Code Category	Code	Rationale
ICD-10-CM	N13.2	Calculus of ureter with hydronephrosis. Add A41.9 (Sepsis, unspecified) and N17.9 (Acute kidney failure) to capture the full clinical picture.
E/M Level	99233	High Complexity MDM. The patient has an acute life-threatening illness (sepsis/AKI due to obstruction). The decision for urgent surgery (stent) and systemic symptoms meet the “High” threshold aapc+1.
CPT Code	52332	cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type) aapc+1.

Explanation: Why 99233?

Under the 2026 guidelines, a 99233 is justified when the medical decision-making (MDM) is high.[aapc]​

• Problem: One acute illness with systemic symptoms (fever/tachycardia) and potential for organ failure (rising Cr) represents a “High” level of complexity.[myihbs]​

• Risk: The risk is high due to the decision for an urgent procedure in the setting of sepsis and acute kidney injury.[aafp]​

• Note: If coding by time, the provider must document at least 50 minutes of total time on the date of the encounter.aapc+1

Procedural Note

The code 52332 specifically includes the visualization of the bladder and the placement of an indwelling stent. If the stone had been removed via lithotripsy during the same session, you would instead look at codes like 52356.aapc+1