Practice Case 2 - {{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.

Case 2: Inpatient Management of Prostatomegaly

Date: February 1, 2026
Patient: 68-year-old male
Chief Complaint: Inability to void for 12 hours and severe suprapubic pain.

History of Present Illness: A patient with a history of Benign Prostatic Hyperplasia (BPH) presents to the hospital in acute urinary retention. Bedside ultrasound reveals 800mL of retained urine. An initial attempt at catheterization by nursing was unsuccessful. The urologist was called for a subsequent hospital consultation. Upon evaluation, the patient is in significant distress.

Assessment & Plan:

1. Acute Urinary Retention (AUR): Secondary to known BPH.
2. Benign Prostatic Hyperplasia (BPH): Significant prostatic enlargement noted on digital rectal exam (DRE).
3. Plan: Patient was taken to the OR for a first-stage Transurethral Resection of the Prostate (TURP) due to failed medical management and recurrent retention.

---

Medical Keyword: Prostatitis

As per our Space guidelines, here is the breakdown of this keyword related to prostate health:

• Short Definition: Inflammation or infection of the prostate gland.​

• Long Definition: A condition often characterized by pelvic pain, urinary symptoms (such as frequency or urgency), and sometimes systemic signs of infection like fever. It can be acute bacterial, chronic bacterial, or chronic pelvic pain syndrome.

• Etymology: Derived from the Greek prostates (“one who stands before”) + -itis (“inflammation”).​

• Related Terms: TURP (Transurethral Resection of the Prostate), Prostatomegaly (enlargement of the prostate), and LUTS (Lower Urinary Tract Symptoms).

---

Answer Key & Rationale (Case 2)

Category	Code	Rationale
ICD-10-CM	N40.1, R33.8	N40.1 captures BPH with lower urinary tract symptoms. R33.8 (Other urinary retention) is added to specify the acute obstruction .
E/M Level	99232	Moderate Complexity. The patient has an acute problem (retention) requiring a management decision for surgery. 99232 is typical for moderate-level subsequent hospital care .
CPT Code	52601	Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete .

Explanation:
Code 52601 is the primary code for an initial TURP. It is a “comprehensive” code, meaning it includes cystourethroscopy, vasectomy, and meatotomy if performed. If this were a repeat procedure for residual tissue years later, 52630 would be used instead.