Crystal's MCW Coder HubPractice Cases
Case 4: Clinical Note: Subsequent Hospital Visit
Date: February 1, 2026
Patient: 68-year-old male
Chief Complaint: Acute urinary retention and severe suprapubic pain.
History of Present Illness:
Patient has a long-standing history of Benign Prostatic Hyperplasia (Urology - BPH Procedures (TURP vs. UroLift)). He presents today with a 12-hour history of inability to void. He reports intense pressure and sharp pain in the lower abdomen. Nursing attempted a standard Foley catheter insertion twice without success due to an enlarged prostate.
Review of Systems/Physical Exam:
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Constitutional: Acutely uncomfortable, perspiring due to pain.
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Abdomen: Distended suprapubic area, extremely tender to palpation.
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Genitourinary: DRE reveals a significantly enlarged (Grade 3+), firm, non-tender prostate.
Labs/Imaging:
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Bladder Scan: Shows 800mL of retained urine.
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Labs: PSA slightly elevated at 4.2; Creatinine stable at 1.0.
Assessment & Plan:
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Acute Urinary Retention (AUR): Secondary to obstructive BPH.[linkedin]
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Benign Prostatic Hyperplasia (BPH): Failed medical management (tamsulosin).
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Plan: Proceed to urgent TURP (Transurethral Resection of the Prostate) to relieve the obstruction. Patient cleared for surgery.
Coding Task: Case 5
Identify the following based on the note above:
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Primary & Secondary Diagnosis (ICD-10-CM)
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E/M Code (Subsequent Inpatient)
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Procedure Code (CPT)
Medical Keyword: Prostatitis
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Short Definition: Inflammation or infection of the prostate gland.[en.wikipedia]
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Long Definition: A condition characterized by pelvic pain and urinary symptoms (frequency/urgency). It can be acute bacterial, chronic, or non-bacterial pelvic pain syndrome.niddk.nih+1
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Etymology: Derived from the Greek prostates (“one who stands before”) + -itis (“inflammation”).[en.wikipedia]
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Related Terms: Prostatomegaly (prostate enlargement) and LUTS (Lower Urinary Tract Symptoms).imedclaims+1
Answer Key & Rationale (Case 5)
| Code Category | Code | Rationale |
|---|---|---|
| ICD-10-CM | N40.1, R33.8 | N40.1 (BPH with LUTS) is the underlying cause; R33.8 (Other urinary retention) specifies the acute manifestation linkedin+1. |
| E/M Level | 99232 | Moderate Complexity. Management of an acute problem (retention) requiring surgical intervention aapc+1. |
| CPT Code | 52601 | Transurethral electrosurgical resection of prostate (TURP), including control of postoperative bleeding aapc+1. |
Case 6: Clinical Note: New Patient Office Visit
Date: February 1, 2026
Patient: 55-year-old female
Chief Complaint: Painless gross hematuria.
History of Present Illness:
Patient reports three days of visible blood in her urine. She denies any associated pain, dysuria, or flank discomfort. She has a significant 30-pack-year smoking history. She has never had this occur previously and denies recent trauma or vigorous exercise.
Review of Systems/Physical Exam:
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Constitutional: Well-nourished, no weight loss.
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Genitourinary: No CVA tenderness. External genitalia appear normal. No masses palpated on pelvic exam.
Labs/Imaging:
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Urinalysis: 3+ blood; negative for nitrites and leukocytes.
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Cytology: Pending.
Assessment & Plan:
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Gross Hematuria: Concerning for urothelial malignancy given smoking history and painless presentation.[en.wikipedia]
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Plan: Perform diagnostic cystourethroscopy in the office. A 0.5cm suspicious papillary lesion was visualized on the posterior bladder wall. A biopsy of the lesion was performed during the same session.
Coding Task: Case 6
Identify the following based on the note above:
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Primary Diagnosis (ICD-10-CM)
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E/M Code (New Patient)
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Procedure Code (CPT)
Medical Keyword: Hematuria
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Short Definition: The presence of blood or red blood cells in the urine.int.livhospital+1
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Long Definition: A medical sign that may be visible (gross) or microscopic. It is a critical finding that necessitates investigation for infection, stones, or tumors.niddk.nih+1
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Etymology: From the Greek haima (“blood”) + ouron (“urine”).[int.livhospital]
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Related Terms: cystoscopy (looking into the bladder) and Pyuria (pus in urine).etymonline+1
Answer Key & Rationale (Case 6)
| Code Category | Code | Rationale | |
|---|---|---|---|
| ICD-10-CM | R31.0 | Gross hematuria. This is the definitive symptom documented during the visit [en.wikipedia]. | |
| E/M Level | 99203 | Moderate Complexity. Evaluation of a new patient with a potentially serious condition (concerning for malignancy) [aafp]. | |
| CPT Code | 52204 | cystourethroscopy, with biopsy(s). This code covers the visualization and the tissue sampling urologytimes+1. |
Final Coding Tips
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Modifier 25: If billing the office E/M (99203) with the biopsy (52204), ensure the E/M documentation supports a “significant, separately identifiable” service beyond the standard prep for the biopsy.[cms]
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BPH Coding: For BPH, always sequence the N40.1 code first, followed by the specific urinary symptom code (like R33.8) to ensure the highest level of specificity.[linkedin]