CDI Adult MDC 12 - Male Reproductive System

Question 1

Benign Hypertrophy of the Prostate
* Definition
* Clinical Indicators
* Treatment

Answer 1

• An overgrowth of prostate tissue experienced by nearly all men, often causing variable degrees of urinary outlet obstruction.
• Clinical indicators – frequency, urgency, nocturia, hematuria, frequent infections, elevated PSA.
• Treatment requires surgical intervention (TURP).

Diagnostics: The diagnostic marker of BPH in most patients is an elevated PSA. PSA is moderately elevated in 30-50% of patients.

Question 2

BPH and Lower Urinary Tract
* When assigning the patient’s BPH Diagnosis, what are the 2 options to choose from?
* What are considered lower urinary tract symptoms?

Answer 2

• When you assign the patient’s BPH diagnosis, you will have 2 options: with or without lower urinary tract symptoms.

N40.0 Prostate
N40.1 with lower urinary tract symptoms
N40.0 without lower urinary tract symptoms

What is considered a “lower urinary tract symptom”:
incomplete bladder emptying
nocturia
straining on urination
urinary frequency
urinary hesitancy
urinary incontinence
urinary obstruction
urinary retention
urinary urgency
weak urinary stream

There are several conditions considered under the broad heading of lower urinary tract symptom, such as nocturia, frequency, hesitancy, retention, and urgency. Assign your patient’s condition best supported by the medical record documentation. However, if there is clinical evidence of a condition, such as frequency, but it is not adequately documented in the medical record, seek clarification from the physician.

Question 3

BPH Complications
As the urethra becomes compromised, secondary complications occur:

Answer 3

• calculi formation (from urinary stasis)
• hydronephrosis (d/t bladder neck obstruction)
• acute renal failure (d/t bladder neck obstruction)

If there is clinical evidence of one of these conditions but it is not documented, ask a question.

Question 4

BPH and Acute Renal Failure

Answer 4

If the condition is present on admission with BPH and meets the definition of principal diagnosis, assign acute renal failure as the principal diagnosis.

• A principal diagnosis of acute kidney injury (AKI) would more accurately reflect severity of illness and risk of mortality and level of care requirement, more so than a principal diagnosis of chronic BPH.

If necessary, seek clarification of the condition, POA status, or both.

Acute renal failure due to blockage from an enlarged prostate is not uncommon in the BPH patient. The physician’s documentation will need to clearly link the ARF/AKI to the BPH.

Question 5

Acute Renal Failure/Acute Kidney Injury

Answer 5

An abrupt decline in renal function, clinically manifesting as a reversible acute increase in nitrogen waste products—measured by blood urea nitrogen (BUN) and serum creatinine levels—over the course of hours to weeks.

RIFLE establishes criteria according to creatinine levels, GFR, and urinary output for risk, injury, failure, loss of function and end-stage renal disease. Other classification systems include AKIN and KDIGO.

Question 6

Documentation Validation

Clarification Example

Clinical Scenario: A 53 yo male was directly admitted from the physician’s office late yesterday afternoon with a diagnosis of “BPH.” His chemistry level drawn on admission reflected a creatinine of 3.7. He does not have a history of CKD. He also complained of weakness and feeling shaky along with a minimal urine stream. His treatment regimen includes an IVF bolus followed by IVFs at 125 cc/hr, repeat BUN and creatinine level q4 hours, strict I&O, and pending urology and surgical consults.

Acute Renal Failure and BPH

Answer 6

Clarification Example
* Acute renal failure, POA due to BPH requiring treatment with IV fluid resuscitation
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: weakness and a creatinine level of 3.7, minimal urine stream
Risk Factor: BPH
Treatment: fluid resuscitation, serial labs, I&O, urology/surgery consults

Question 7

TURP
* Generally performed for what condition?
* Complications include?
* The TURP assignment is dependent on what?
* What Root Operation is used to index this procedure?

Answer 7

• Generally performed for moderate to severe urinary flow obstruction due to overgrowth of prostate tissue (BPH).
• Complications: Post-op urinary retention, cath-rel UTI, ABLA, incontinence, post-op hyponatremia.
• The assignment of TURP is dependent on principal diagnosis.
• Root Operation = Excision

Excision Cutting out/off, without replacement, a portion of a body part

During a TURP the surgeon excises excess (hypertrophied) prostate tissue. Use the root operation EXCISION to index the procedure

TURP, as a surgical DRG assignment, is available in multiple MDCs. If necessary, clarify the patient’s diagnosis with the physician.

Question 8

TURP Secondary Diagnosis: Acute Blood Loss Anemia

Answer 8

You are not allowed to assume a diagnosis of acute blood loss anemia from a diagnosis of “blood loss anemia” – the physician must provide explicit documentation of the condition.

• Acute blood loss anemia (acute post hemorrhagic anemia) is a condition in which a person quickly loses a large volume of circulating hemoglobin. The condition is usually associated with an incident of trauma, but it can also occur during or after a surgical procedure.

There is no specific lab value or parameter used to identify acute blood loss anemia as each lab has their own facility-specific values. However, a low H&H, serial monitoring of the H&H or blood transfusion may be a clinical clue of what the physician may be thinking and treating, but not documenting.

Question 10

Urolift - Coding Clinic 4Q2013, p123

Question: Provider documentation states rigid cystoscopy, transurethral placement of four transprostatic permanent retraction devices utilizing the UroLift System to treat benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms.

What is the correct ICD-10-PCS code assignment for this procedure?

Coding Clinic Advice

Answer 10

Answer:
Assign the following ICD-10-PCS code for this procedure utilizing the UroLift System:

0T7D8DZ Dilation of urethra with intraluminal device, via natural or artificial opening endoscopic

The UroLift System is utilized to treat lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). This minimally invasive technology is designed to open the urethra by moving back the obstructing prostatic lobes. This is done without incisions, resection or thermal injury to the prostate.

Explanation:For some BPH patients, a Urolift procedure may be the treatment of choice instead of a TURP. It is a minimally invasive procedure during which the surgeon endoscopically dilates the urethra with a series of strategically placed stents. The root operation used for this procedure is dilation rather than excision.

Question 11

Infection and Sepsis

Answer 11

• If a diagnosis of sepsis is validated as present on admission, assign sepsis as the principal diagnosis.
• If sepsis develops after the time of admission, assign sepsis as a secondary diagnosis.

SIRS may be clinically indicated by any 2 of the 4 following indicators in the presence of an infectious process:
― Temperature > 38°C or < 36°C

― Heart rate > 90/min

― Respiratory rate > 20/min or PaCO2 < 32 mmHg

― WBC > 12,000/mm3 or < 4000/mm3 or > 10% immature bands

If the clinical evidence supports sepsis, seek clarification from the physician.

Question 13

sepsis documentation sample clarification

Sample Clarification
Scenario: A 34 yo male presents to the ED with complaints of low pelvic pain, difficult urination, fever and increasing lethargy x5 days. Triage VS are noted as: T102.4, P102, R22, BP 112/68. Stat blood work reveals a WBC at 25.6 with 12% bandemia. He is admitted to ICU with a diagnosis of “acute prostatitis with bandemia.” His treatment regimen includes IV vancomycin.

Documentation Management

Answer 13

Sample Clarification:
* Sepsis, POA due to acute prostatitis requiring admission to ICU and treatment with IV vancomycin
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: T102.4, P102, R22, WBC 25.6, 12% bandemia, increasing lethargy
Risk Factor: delayed treatment for acute prostatitis
Treatment: ICU admission, IV vancomycin

Explanation:A 34-year-old male was admitted with acute prostatitis and bandemia. But the review of the clinical presentation reveals a temp of 102.4, p102, r22, an elevated WBC at 25.6 and 12% bands. He’s been admitted to ICU and is receiving IV vancomycin.

His clinical presentation seems a bit more systemic than a localized infection. Here’s what we’ll ask the physician: sepsis, present on admission, due to acute prostatitis requiring admission to ICU and IV vancomycin.

Question 14

Prostate Cancer
* Clinical Indicators
* Risk Factors
* Treatment

Answer 14

• One of the most common types of cancer in men.
• Clinical indicators - dysuria, decreased urinary stream, blood in the semen, pelvic pain, bone pain and erectile dysfunction.
• Risk factors include advancing age, obesity, a family history, and race (African American).
• Treatment requires surgical intervention, chemo and/or radiation.

Question 15

Stages of Prostate Cancer

Answer 15

• Stage I: very early stage; cancer confined to a small area of the prostate
• Stage II: cancer cells not confined to a small area of the prostate; may involve both sides of the prostate
• Stage III: cancer cells have spread from the prostate to the seminal vesicles or other tissue within close proximity of the prostate
• Stage IV: metastatic disease with invasion of the cancer into other organs such as the lymph nodes, bones, lungs, bladder

Question 17

Chapter-Specific Coding Guidelines

What are the Coding Guidelines for the following:
Treatment directed at the malignancy
Treatment of secondary site

Neoplasm Official Coding Guidelines

Answer 17

Treatment directed at the malignancy
* If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.
* The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy, assign the appropriate Z51.– code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.
Treatment of secondary site
* When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.

Question 18

Testing Knowledge

Clinical Scenario: A 42 yo male with “stage 3 prostate cancer” is admitted for a trial of Juvtana chemotherapy after failing therapy with Taxotere.

Questions
1) This patient’s PDX is:
A. Prostate Cancer
B. Carcinomatosis
C. Encounter for chemotherapy

Neoplasms

Answer 18

Answer: C. Encounter for chemotherapy

Explanation: Even though the primary site is still present and a current diagnosis, the patient was admitted for chemotherapy administration

Question 19

Toxic Gastroenteritis

Answer 19

Chemotherapy can cause inflammation anywhere along the GI tract resulting in the symptoms generally associated with “GE.” Gastroenteritis caused by chemotherapy, or exposure to other toxic substances, is referred to as “toxic gastroenteritis.”

*Important Note: The inclusion terms for toxic gastroenteritis include drug-induced gastroenteritis, drug-induced colitis, and drug-induced diarrhea.

Question 21

Toxic Gastroenteritis Clinical Example

Scenario: A 17 yo male has been admitted with “non-infectious GE” (N/V) after his second round of chemotherapy. He is currently being treated for stage 2 testicular cancer. C-diff and other differential diagnoses have been ruled out. His treatment regimen includes NPO status, antibiotics and IV fluids.

Answer 21

Sample Clarification:
* Toxic gastroenteritis due to chemotherapy requiring treatment with IV antibiotics and IV fluids
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: “non-infectious GE”
Risk Factor: chemotherapy
Treatment: IV fluids, antibiotics, NPO status

Question 22

Prostate Cancer/Treatment Complications

Answer 22

Complications associated with prostate cancer or the treatment for the condition include:

toxic gastroenteritis
acute renal failure
acute blood loss anemia
urinary incontinence
erectile dysfunction
tumor lysis syndrome
non-infectious SIRS
pancytopenia d/t chemotherapy
metastasis (bones, lymph nodes, lungs, liver, brain)

If there’s clinical evidence of a complication but it’s not documented in the medical record, seek clarification from the physician.

Question 23

Chemotherapy Administration
* Is Chemotherapy Administration a Valid or Non-Valid OR Procedure?
* What Root Operation will be used to index the procedure?
* If the Principal Diagnosis changes, will the Root Operation change?

Answer 23

• Chemotherapy administration is a non-valid OR procedure
• During chemo administration, a therapeutic product is being introduced into the patient’s body. You will use the root operation INTRODUCTION to index the procedure.
• You’ll use the root operation INTRODUCTION regardless of your patient’s principal diagnosis.

Introduction: putting in or on a therapeutic substance except blood or blood products

Question 24

Radiation Therapy
* Is Radiation Therapy a Valid or Non-Valid OR Procedure?
* What Root Operation is used?
* How can Radiation be delivered to the patient? Will this change the Root Operation used to index the radiation protocol?
* What character descriptions are required to be identified by the coder?

Answer 24

• Radiation therapy is a non-valid OR procedure.
• Radiation can be delivered either as beam radiation or as brachytherapy.
• Use the root operation that describes the patient’s radiation protocol, e.g., BEAM RADIATION or BRACHYTHERAPY.
• The coder will identify the treatment part, the modality qualifier, the isotope and the qualifier.

The character descriptions are obtained from the procedure note. If you are still unsure of a character, ask a question.

Question 25

Brachytherapy

Answer 25

Devliers radioactive seeds directly to the tumor

Radiation Therapy treatment option for Prostate Cancer

Question 26

Prostatectomy
* Definition
* The proedure may be performed using 2 approaches; what are they?
* What is the Root Operation used to index the procedure?
* What must the coder do if lymph nodes or lymph node chains are involved in this procedure?

Answer 26

• The complete removal of the prostate. The procedure may include the resection/excision of a lymph node chain or single node(s)
• This major procedure may be performed using one of two approaches: open or laparoscopic.
• During the performance of a radical prostatectomy, the surgeon removes the entire prostate gland. You will use the root operation RESECTION to index the procedure.

*Remember to include any excision/resection of lymph node(s) or lymph node chain.

Question 27

Robotic Assisted Lap Prostatectomy-Coding clinic 4Q2014, p33

Question: A patient presents for robotic-assisted laparoscopic radical prostatectomy. During the procedure partial removal of the bilateral vas deferens was accomplished and the bilateral seminal vesicles were removed.

Does a radical prostatectomy include resection of the vas deferens and seminal vesicles or should these procedures be coded separately? What are the appropriate code assignments for robotic-assisted laparoscopic radical prostatectomy?

Coding Clinic Advice

Answer 27

Answer: Radical procedures can have different meanings depending on the procedure, and the term “radical” is not always reliable information for coding the procedure. The coder should instead be guided by the information in the operative report. In ICD-10-PCS, code separately the organs or structures that were actually removed and for which there is a distinctly defined body part. The ICD-10-PCS guideline B3.2a states if during the same operative session the same root operation is repeated at different body sites that are defined by distinct values of the body part character, multiple procedures should be coded.

The robotic assistance may be coded if desired. For this case, based on the documentation in the submitted operative report, assign ICD-10-PCS codes as follows:

0VT04ZZResection of prostate, percutaneous endoscopic approach, for the resection of the prostate
0VT34ZZ Resection of bilateral seminal vesicles, percutaneous endoscopic approach, for the resection of the bilateral seminal vesicles
0VBQ4ZZ Excision of bilateral vas deferens, percutaneous endoscopic approach, for the partial removal of the bilateral vas deferens
8E0W4CZ Robotic assisted procedure of trunk region, percutaneous endoscopic approach

Explanation:This 2014 Coding Clinic is important – not only because it provides advice regarding a robotic assisted laparoscopic radical prostatectomy, but because it also reminds us to review the body of the operative report. The patient in question underwent radical prostatectomy that also included the partial removal of the vas deferens and the seminal vesicles. The question is whether the procedures involving these adjacent structures should be captured. According to Coding Clinic, the operative report should be reviewed and the organs or structures that were removed should be captured and coded. Remember, never assign a procedure without reviewing the body of the operative note

Question 28

Lymph Node Dissection Root Operations

Answer 28

Resection: cutting out or off, without replacement, all of a body part
Excision: cutting out or off, without replacement, a portion of a body part

• If a chain of lymph nodes is excised, it should be coded as resection.
• If a partial removal of the lymph node chain is done, it is coded as excision.
• If the intent is to remove all of the lymph nodes in an area, code as resection. A radical resection implies removal of all of the lymph nodes.

A radical prostatectomy may/may not include the removal of lymph nodes.

Question 29

Clinical Scenario:Triage NN: a 72 yo male presents to the ED with c/o inability to urinate for 6 hrs
VS: 166/94, 98, 22, 98.1, 02 sat at 99% on RA

PMH: BPH, HTN, CAD

Meds: Flomax, Norvasc, Plavix
Diagnostics: CT negative for hydronephrosis
Impressions:
ED: suprapubic pain…straight cathed for 840 mls
H&P: 72 yo male well known to me… 3rd admission d/t “BPH”…will not agree to surgical intervention…urology consult pending…Foley cath draining clear urine

Questions:
1)The patient’s principal diagnosis is BPH. Based on your review of the medical record: Is there evidence of a lower urinary tract symptom? Yes or No

2)What is it? (What is the lower urinary tract symptom?)
A. Urinary Urgency
B. Urinary Retention
C. Urinary Hesitancy
D. Urinary Incontinence

3) Can you assume this diagnosis based on the clinical evidence or must you clarify?
A. Assume the diagnosis
B. Clarify

Answer 29

Answers:
1) Yes
2) B. Urinary Rention
3) Clarify

Explanation: So, we have a 72-year-old male presenting to the ED complaining with the inability to urinate for 6 hrs. His vital signs seem to be within normal limits. He does have a history of BPH and takes Flomax every day. He is straight cathed in the ED for over 800 ccs and is admitted with BPH.

Did you identify the opportunity to clarify for a lower urinary tract symptom of urinary retention? Although clinically we recognize the diagnosis of retention, we must clarify the diagnosis with the physician. If you missed this scenario, you’ll need to remediate the content for BPH.

Question 30

Clinical Scenario: A 63 yo male has been admitted with “acute cellulitis of the scrotum.” On admission to the ED, he was lethargic with a T 102.2, P 94, R 22, and BP 126/68. His WBC was noted as “elevated” at 33 with 12 bands. He has been admitted to the ICU and started on IV Gentamycin.

Questions:
1) What is the patient’s principal diagnosis?
2) There is clinical evidence of a potential alternative principal diagnosis. The potential alternative PDx is:

Answer 30

Answers:
1) Acute cellulitis of the scrotum
2) Sepsis, present on admission

Explanation: This 63 yo male has been admitted with a principal diagnosis of acute cellulitis of the scrotum. This is unusual since most patients do not require admission for cellulitis of the scrotum. However, as we review the patient’s clinical presentation and aggressive treatment regimen, we have to wonder if the physician is thinking and treating a diagnosis of sepsis that was present on admission. If you missed these questions, please remediate the content for infections and inflammations.

Question 31

MDC 12 Surgical DRG Assignment

Answer 31

In MDC 12, there are 5 categories of surgical DRG assignment:
― Major Pelvic Procedures
― Penis Procedures
― Testicular Procedures
― TURP
― Other Procedures with/without Malignancy

*Important Note: Remember some of the male procedures also assign to other MDCs, such as the prostatectomy. For this reason, accurate assignment of the patient’s principal diagnosis is of the utmost importance, when in doubt – seek clarification from the physician.