Urinary, male genital, and endocrine systems

CHAPTER 10


Urinary, male genital, and endocrine systems




Urinary system


Common urinary symptoms are nocturia, polyuria, hematuria, proteinuria, dysuria, oliguria, urinary incontinence, and enuresis. Often treated urinary conditions include hypercalciuria (urinary stones caused by the body’s inability to process calcium properly), renal failure, pyelonephritis, and infections as well as kidney and bladder cancer. A physician who specializes in the diagnosis and treatment of conditions of the urinary system is a urologist. A urologist also specializes in male genitourinary conditions and often treats patients with prostatitis, benign prostatic hyperplasia, and prostate cancer. Urology is classified as a surgical subspecialty. A nephrologist specializes in the treatment of conditions of the kidney and has special education and training in kidney disease and dialysis therapy as well as transplantation. Nephrology is a subspecialty of internal medicine.




Diagnosis coding


For a refresher on diagnosis coding for renal failure, refer back to the information that appears before Case 1-8 in Chapter 1.



CASE 10-1   10-1A Operative Report, Kidney Biopsy


CASE 10-1


The patient in this case was in chronic renal failure with blood (hematuria) and excess protein (proteinuria) in her urine. Dr. Avila performs a percutaneous kidney biopsy. Report only Dr. Avila’s service.



10-1A  Operative report, kidney biopsy


LOCATION: Outpatient, Hospital


PATIENT: Maria Ace


SURGEON: Ira Avila, MD


RADIOLOGIST: Morton Monson, MD


PROCEDURE PERFORMED: Kidney biopsy


INDICATIONS: Chronic renal failure, hematuria, and proteinuria


DESCRIPTION OF PROCEDURE: The patient was placed in the prone position. The right kidney was visualized using ultrasound provided by Dr. Monson. The skin was prepped in the usual fashion. One-percent lidocaine was used for local anesthesia. Multiple core biopsies were obtained under real ultrasound guidance using an 18-gauge biopsy gun without difficulty. Multiple core biopsies were obtained and were sent for light electromicroscopy and immune fluorescence.


The patient tolerated the procedure well and without immediate complications. She will be sent back to the procedure area to be monitored in 6 hours with repeat hemoglobin on her.


Pathology Report Later Indicated: Renal cell adenocarcinoma, primary





Nephrostomy tube


A nephrostomy tube is a small, flexible tube that is placed into one or both kidneys to drain urine when the kidney is not filtering properly. The tube can be placed temporarily, such as when a patient is being prepared for removal of a large kidney stone, or permanently, such as when the kidney is unable to excrete urine on its own. The ureter may also be blocked by a stone, tumor, infection, or scarring. In some settings, the interventional radiologist would conduct these placements or replacements of nephrostomy tubes using ultrasound or x-ray to locate the kidney.



CASE 10-2   10-2A Radiology Report, Nephrostogram 10-2B Operative Report, Nephrostomy Tube Exchange


CASE 10-2



10-2A  Radiology report, nephrostogram


At times, the kidney of a patient with a nephrostomy tube will require examination by means of contrast being injected into the kidney using the existing nephrostomy tube. Dr. Avila referred Richard Arco to Dr. Monson for an x-ray due to a bloody discharge from Richard’s nephrostomy tube. Dr. Monson provided the injection procedure and supervision or interpretation. The diagnoses codes for this case will be for a complication of a urinary catheter and ureter obstruction.


LOCATION: Outpatient, Hospital


PATIENT: Richard Arco


SURGEON: Ira Avila, MD


RADIOLOGIST: Morton Monson, MD


EXAMINATION OF: Nephrostogram


CLINICAL SYMPTOMS: Bloody drainage from nephrostomy tube


NEPHROSTOGRAM: HISTORY: A 69-year-old man presents with a longstanding right nephrostomy tube. Recently he has had blood drainage from the nephrostomy tube. The patient’s creatinine is 2.5, PT (prothrombin time) 23.1, INR (International Normalized Ratio) 4.0, and PTT (partial thromboplastin time) 52.9. Hemoglobin is stable at 10.7 (last Monday it was 10.6).


FINDINGS: Nephrostogram was performed and compared with the prior study of last month. The patient had been doing well until several days ago, when he started to experience bloody discharge. The patient describes a situation where the tube may have been retracted while he was sleeping. INR is 4.0. Nephrostogram was performed and is basically unremarkable. There continues to be distal right ureter obstruction (this is the indication of the ureter obstruction), and the lower pole calyces are not well identified, and they were not present previously as well. There may be a single calyx (not a reported diagnosis as it is not confirmed), which is not seen today. The locking pigtail mechanism is at the edge of the renal pelvis and was advanced several centimeters into a more secure position in the mid to distal renal pelvis. There is no evidence of extravasation or clot within the collecting system. With the patient’s coagulation times as abnormal (this is a diagnosis of abnormal blood chemistry, but it is not reported because it is not the reason the service is being provided; rather, it is an incidental finding) as they currently are, I felt it was not worth any risk of losing access, and we would just leave the current tube in position. We agree that discontinuing Coumadin at least for a time is worthwhile in hopes of normalizing his coagulation times so that we could discontinue the current problem. The bloody discharge is a serosanguineous fluid. It is mixed with both urine and blood. There were really only a few minimal clots that came with gravity drainage from this. Once the patient’s coagulation times are normalized, we will follow this closely, and perhaps at that time we will plan to do other interventions. Again, the patient’s hemoglobin is stable. It is 10.7 today and was 10.6 on last Monday.


IMPRESSION: Nephrostogram is basically unremarkable. See above comments.




10-2B  Operative report, nephrostomy tube exchange


The patient in this case requires replacement of a previously placed nephrostomy tube. The diagnosis is the reason for the service, which in this case will be a Z/V code for attention to an artificial opening. No guidance is mentioned in this report; however, there was a radiologic exam performed.


LOCATION: Outpatient, Hospital


PATIENT: Richard Arco


SURGEON: Ira Avila, MD


EXAMINATION OF: Right nephrostomy tube exchange


CLINICAL SYMPTOMS: Routine exchange of nephrostomy tube


RIGHT NEPHROSTOMY TUBE EXCHANGE: HISTORY: An 82-year-old man presents for routine exchange of nephrostomy tube.


FINDINGS: The patient was prepped and draped in the standard fashion. Through the existing no. 8-French nephrostomy tube, contrast was infused (injection procedure done by radiologist) and demonstrated sharp calyces and a well-formed renal pelvis with normal flow of control into the distal right ureter to the level of the uterovesical junction, which is the known site of obstruction. There is no evidence of contrast extending into the bladder. No filling defects or calculi were evident. Then, with standard wire and catheter exchange techniques, the no. 8-French nephrostomy tube was exchanged for a new no. 8-French nephrostomy tube. The locking mechanism pigtail was in the right renal pelvis. There were no complications. The patient tolerated the procedure well. The patient did not receive conscious sedation.


IMPRESSION: Successful exchange of no. 8-French right nephrostomy tube. The patient requires routine 3-month exchanges of right nephrostomy tube.





Urinary system subcategories


Open the CPT manual to the Urinary System subsection. There are the following categories:



It is very important to know the anatomy of the urinary system when coding from the subsection. It is all too easy to report the wrong code, as all of the categories have many of the same types of subcategories. For example, it is easy to report the wrong code when reporting a procedure of the ureter(s) or the urethra. Make certain you are in the correct category before assigning a code. Also, write in your CPT manual next to Ureter (50600-50980) “kidney(s) to bladder” and next to Urethra (53000-53899) “bladder to external body.” These types of notes will personalize your coding manuals and make them more helpful to use.



Urinary system cysts


Code Q61.0-/753.1- is assigned to congenital cysts of the kidney. M28.1/593.2 is assigned to acquired cysts of the kidney (peripelvic [lymphatic] cyst), and a ureteral polyp and ureterocele is reported with N28.89/593.89. If there is no diagnostic statement as to whether the cyst is congenital or acquired, assign an acquired diagnosis.


ICD-10-CM: Reference “Cyst, kidney (acquired)” in the index of the ICD-10-CM to be referred to N28.1 and to locate the other codes under that term, such as “Cyst, kidney, congenital Q61.00.”


If the condition is an acquired calculus of the kidney or ureter, code N20.- is assigned. If the calculus is a congenital condition, assign Q63.8. If there is no diagnostic statement as to whether the calculus is congenital or acquired, assign an acquired diagnosis code. This is because in the Index of the ICD-10-CM, under the main term “Calculus, kidney,” there is a subterm for “congenital,” so unless the stone was specifically stated as congenital, it would be coded as acquired, even though there is no acquired terminology in the Index under the term “calculus.”


ICD-9-CM: Assign a congenital diagnosis code because in the Index of the ICD-9-CM under the term “Cyst, kidney” the term “(congenital)” is a nonessential modifier, so the cyst does not need to be stated as “congenital” for 753.1X to be assigned. Review the additional terms available under the subterm “kidney,” such as simple, single, or multiple, so that you will know the Index location of these types of cysts for future reference.


image
FIGURE 10–1 Urinary cysts.

If the condition is an acquired calculus of the kidney or ureter, code 592.X is assigned. If the calculus is a congenital condition, assign 753.3. If there is no diagnostic statement as to whether the cyst is congenital or acquired, assign an acquired diagnosis code. This is because in the Index of the ICD-9-CM, under the main term “Calculus, kidney,” there is a subterm for “congenital,” so unless the stone was specifically stated as congenital, it would be coded as acquired, even though there is no acquired terminology in the Index under the term “calculus.”


Further congenital abnormalities of the urinary system include:




























Q60.-/753.0- Renal agenesis (absence of an organ) or dysgenesis
Q61.-/753.1- Cystic kidney disease (cysts of kidney)
Q62.–/753.2- Obstructive defects of the renal pelvis and ureter
Q63.3-/753.3 Other specified anomalies of the kidney or ureter (includes calculus) and kidney abnormalities (horseshoe kidney)
Q64.1-/753.5 Exstrophy (turning inside out) of the urinary bladder
Q64.3-/753.6 Atresia (absence of external opening) and stenosis of urethra and bladder neck,
Q64.4/753.7 Anomalies of urachus (connects urinary bladder with umbilicus in fetus)
Q64.5-Q64.79/ 753.8 Other anomalies of the bladder and urethra (such as hernia of bladder and prolapse of bladder)


CASE 10-3   10-3A Operative Report, Nephrectomy


CASE 10-3



10-3A  Operative report, nephrectomy


LOCATION: Inpatient, Hospital


PATIENT: Rosa Alvarado


SURGEON: Ira Avila, MD


PREOPERATIVE DIAGNOSIS: Multicystic, dysplastic left kidney


POSTOPERATIVE DIAGNOSIS: Multicystic, dysplastic left kidney


PROCEDURE PERFORMED: Left laparoscopic radical nephrectomy


CLINICAL NOTE: The patient was found to have a multicystic, dysplastic kidney on investigation for abdominal pain. There are multiple complex cysts of this kidney. It is grossly enlarged. There is no way to determine whether there are malignant changes. It is decided to proceed with attempt at laparoscopic nephrectomy for removal of this. Renogram showed the primary dominant kidney to be the right kidney.


OPERATIVE NOTE: The patient was given a general endotracheal anesthetic, prepped, and draped in the left flank position. Foley catheter was placed, and an orogastric tube was placed. Hassan trocar was placed two fingerbreadths above and lateral to the umbilicus at the lateral margin of the rectus fascia. Two further 12-mm (millimeter) ports were placed in the right lower quadrant under visual guidance, and a 5-mm port was placed in the subcostal position in the anterior axillary line.


The colon was mobilized off the kidney. The kidney was grossly enlarged. Cysts could be seen bulging through perirenal fat.


The kidney was mobilized, and the renal hilum was identified. The ureter was identified just below the lower pole of the renal kidney, where it was doubly clipped and divided and used for retraction. A single renal vein and renal artery were identified. The renal artery was in a posterior superior position. This was triply clipped on the patient’s side and doubly on the specimen side and divided. The linear GIA was then utilized to clip the renal vein. It was decided to try to spare the adrenal gland, and therefore Gerota’s fascia superior to the kidney was taken, but the adrenal gland was left in situ. A harmonic scalpel was used for mobilization. Multiple collateral vessels were around the kidney and desmoplastic reaction. At one point during mobilization, the cyst was entered and the contents spilled. These were evacuated during suction. Then the wound was irrigated at this point and then subsequently. The specimen was ultimately mobilized and freed. It was placed in a large lap sac, and the lap sac was brought through the Hassan trocar site. The wound was draped with clean towels, and the kidney was morselized using the sponge forceps. All cyst fluid was suctioned from the bag and sent for cytologic evaluation. A total of 600 cc (cubic centimeter) of fluid was obtained. The specimen was also sent for pathology. A small pale nodule was identified during the morselization, and this was sent separately as the renal mass.


Gown and gloves were changed; green towels were removed and Hassan trocar reintroduced. The wound was thoroughly irrigated using 1 L of Kefzol/heparin in normal saline. Hemostasis was ensured. The 12-mm trocar sites were closed using a GraNee needle and 2-0 Vicryl. Peritoneum and external oblique fascia were closed in the Hassan trocar site using 2-0 Vicryl. Skin was closed with subcuticular Dexon. Sponge and needle counts were reported correct. The patient tolerated the procedure well and was transferred to the recovery room in good condition.


ESTIMATED BLOOD LOSS: 100 cc


Pathology Report Later Indicated: Multiple, benign renal cysts




Renal calculus


Renal calculus is a kidney stone and often causes excruciating pain. Stones form due to structural disorders, metabolic abnormalities, or recurrent urinary tract infections. Structural abnormalities such as cysts of the kidney (polycystic kidney disease), obstructions, and malformed kidneys predispose stone formation. Metabolic conditions (e.g., hypercalciuria and hyperuricemia) that increase the body’s production of calcium increase the chances of kidney stone. Most stones are composed of calcium and magnesium, although stones of other constituents are not uncommon.


Stones are very small, with a usual diameter of 1.5 cm or smaller. X-ray (KUB), CT scan, or ultrasound may be useful to visualize the stone. Stones usually pass spontaneously but on occasion may require intervention. Methods of removal include pharmaceuticals that dissolve calcium-based stones, percutaneous removal, transurethral ureteroscopy, extracorporeal shock wave lithotripsy (ESWL), or even open surgical removal. ESWL is the use of ultrasound to shatter the stone so the fragments will then usually pass spontaneously.



From the Trenchesimage


“Coding is like solving a mystery. . . . I think it is like detective work. There are some easy codes that you’ll find very quickly, but there are others that take a great deal of intellect and research to determine whether or not you are actually getting it right.”


JOHN



CASE 10-4   10-4A Operative Report, ESWL


CASE 10-4



10-4A  Operative report, ESWL


LOCATION: Outpatient, Hospital


PATIENT: Juan Santos


SURGEON: Ira Avila, MD


PREOPERATIVE DIAGNOSIS: Left renal calculus


POSTOPERATIVE DIAGNOSIS: Left renal calculus


PROCEDURE PERFORMED: Left ESWL (extracorporeal shock wave lithotripsy)


CLINICAL NOTE: This gentleman came in with renal colic, and a stent was placed. He had his anticoagulation reversed and presents now for ESWL.


The patient was given a general laryngeal mask anesthetic, prepped, and draped in the supine position. Stone was targeted and shock head engaged. A total of 2400 shocks at maximum KV and stone partial fragmentation and dissolution could be seen. The patient tolerated the procedure well and transferred to the recovery room in good condition. He will be seen in follow-up in 2 weeks’ time for KUB (kidney, ureter, bladder).




Urodynamics


Urodynamics is used to study how the bladder stores and releases urine, such as the bladder capacity and ability of the bladder to empty completely. Circular muscles (sphincters) close tightly around the urethra to prevent the leakage of urine (incontinence). If the urinary problem is related to nerve damage, electrodes (electromyographic [EMG] electrodes) may be placed into the urethra and rectum to assess the response of these muscles. When EMG electrodes are used as a part of the urodynamic study, they are reported separately. Another component of the urodynamic assessment may be a cystometrogram (CMG), in which a small catheter is placed into the bladder and warm water is placed into the bladder to measure the capacity of the bladder. Leak point pressure can also be assessed by means of the CMG when the patient coughs with a full bladder. The CMG can also measure the pressure required to urinate with a voiding pressure study (VCUG) that is reported separately. X-ray or ultrasound (video urodynamics) may also be used to image the filling and emptying of the bladder. Contrast material is added to the liquid that is used to fill the bladder to enhance the image.


The notes preceding the Urodynamic codes 51725-51798 indicate that if the physician interprets the results or operates the equipment, modifier -26 is to be added to identify that only the professional component of the service was provided. When codes in this category are reported without -26, that use indicates that the professional and technical components of the service were provided. If, however, the urodynamic assessment was provided by a clinic physician in the outpatient department of the hospital, the hospital would report the technical component and the physician would report the professional component with the -26 modifier.



CASE 10-5   10-5A Urodynamic Assessment


CASE 10-5


The following report indicates the components that are to be coded with bold typeface. You are reporting the professional component of the service, so remember to use the correct modifier (-26) to indicate only the professional component of the service. Because there are multiple procedures, you will need to indicate that with a modifier. Remember to place the modifiers on the code in descending order with the highest-numbered modifier first followed by the lower-numbered modifier.



10-5A  Urodynamic assessment


LOCATION: Outpatient, Hospital


PATIENT: Elva Sexton


SURGEON: Ira Avila, MD


DIAGNOSIS: Chronic renal failure


This lady is referred for urodynamic assessment prior to renal transplantation. Previous attempts were unsuccessful in that she was having what appeared to be a significant hypoglycemic episode and was referred to the emergency room. I have not heard of any follow-up from our emergency department in this regard. The patient presents now.


Uroflow: (This is the uroflowmetry service.)







Cystometrogram: (This is the cystometrogram service.)


Urethral and rectal catheters were placed. EMG electrodes applied. The patient was placed in a semisitting position.






No evidence of uninhibited bladder contractions was seen. Leak point pressure (This is the voiding pressure study of the bladder.) was not established with Valsalva in excess of 80 cm (centimeter) of water. The patient could not void with the Foley catheter in situ. She did void by Valsalva. Pressure flow showed no evidence of obstruction. EMG activity was normal.


Once the catheter was removed, the patient was able to void easily without evidence of Valsalva and voided to completeness.


ASSESSMENT: No evidence of uninhibited bladder contractions. Normal bladder capacity. The patient was unable to void with catheter in situ, but normal uroflow study and post EMG voiding suggest normal detrusor function.




Stress incontinence


Stress incontinence is involuntary loss of urine that is usually associated with activities that increase the bladder pressure, such as coughing, sneezing, or exercising. This is a condition that most often occurs in women due to physical changes resulting from pregnancy, childbirth, and menopause. The pelvic floor muscles that support the bladder become weakened and the bladder moves downward (prolapses), preventing the muscles (sphincters) that would force the urethra shut from contracting properly, resulting in leakage. After more conservative treatments have failed, surgery may be used to alleviate the incontinence, such as a wing sling that holds the bladder up and returns it to normal position.



CASE 10-6   10-6A Operative Report, Urethropexy


CASE 10-6



10-6A  Operative report, urethropexy


LOCATION: Outpatient, Hospital


PATIENT: Jan Barens


SURGEON: Ira Avila, MD


PREOPERATIVE DIAGNOSIS: Stress incontinence


POSTOPERATIVE DIAGNOSIS: Stress incontinence


PROCEDURE PERFORMED: Anterior urethropexy


CLINICAL NOTE: The patient is a 59-year-old woman who has stress incontinence. She is undergoing oophorectomy and colposuspension for enterocele. She also has stress incontinence and a hypermobile urethra.


PROCEDURE: The patient was already open and had undergone bilateral oophorectomy by Dr. Sanchez. Prior to apical suspension, I was asked to perform her anterior urethropexy.


The Foley catheter was in situ. With a finger in the vagina, the urethra was identified and sutures were placed bilaterally at the mid-portion of the urethra 1 cm (centimeter) lateral and at the bladder neck 2 cm lateral. These sutures were then suspended to Cooper’s ligament bilaterally. The sutures were tied down to elevate the urethra to the horizontal position. One finger could be passed between the urethra and the symphysis anteriorly. Hemostasis was ensured.




Bladder rupture


The bladder is ruptured when pressure is placed on a distended bladder. This type of injury is often associated with seatbelt injury in which extreme force results in a compression rupture and most often results in a laceration of the dome of the bladder. The bladder is repaired by means of suture repair (cystorrhaphy) of the resulting lacerations either by percutaneous or open abdominal surgical approach.



CASE 10-7   10-7A Operative Report, Intraperitoneal Bladder Rupture


CASE 10-7



10-7A  Operative report, intraperitoneal bladder rupture


This is an internal injury to the bladder as a result of a fall from a ladder that required a complicated repair. The injury is the primary diagnosis followed by an external cause/E code to indicate how the injury happened.


LOCATION: Inpatient, Hospital


PATIENT: Racio Ruiz


SURGEON: Ira Avila, MD


PREOPERATIVE DIAGNOSIS: Intraperitoneal bladder rupture


POSTOPERATIVE DIAGNOSIS: Intraperitoneal bladder rupture


PROCEDURE PERFORMED: Repair of retroperitoneal bladder rupture


INDICATIONS: This is a 22-year-old man who sustained an intraperitoneal bladder rupture secondary to a fall from a ladder.


ANESTHESIA: General


PROCEDURE: The patient was brought to the operative theater and placed in the supine position on the operating table. After receiving a general anesthetic, he was prepped and draped in a sterile fashion. A vertical midline incision was made from a little above the umbilicus down to the pubis. Dissection was carried down through the subcutaneous tissues and through the anterior fascia. The peritoneal cavity was entered sharply. Some blood clots down in the pelvis were seen overlying the bladder. This area was packed off. We then examined the rest of the abdomen. There were no blood or fluid collections elsewhere. We did not extend the incision all the way up to the top, so it was difficult to get good visualization of the liver and the spleen; however, there was no blood in this area, and palpation of them revealed no abnormalities. The stomach felt normal. Orogastric tube showed good placement. The small bowel was run from the ligament of Treitz to the terminal ileum. This was fine. The appendix was present and normal. The colon was grossly normal throughout its length. Some stool was present. No gross abnormalities were seen down to the pelvis. We had to remove the packing. There were some blood clots setting in the bladder itself. He had a fairly long laceration (indicates complexity) that was for the most part vertical and went fairly close to the superior anterior aspect and continued about two thirds of the way down, pretty much right over the dome (indicates complexity). We inspected the inside of the bladder. No other lesions or lacerations could be identified. We then closed this in two layers (indicates complexity). The inner layer was a 3-0 Vicryl in a running fashion. We then imbricated all of this with interrupted sutures of 3-0 Vicryl through the serosa/peritoneum. There was another bit of lateral laceration that was not full thickness but involving just the serosa. This was also repaired with interrupted sutures of 3-0 Vicryl in a Lembert fashion. This was to the left side, and there was also another short one to the right side. We made sure that each of the corners/apexes had a three-corner stitch placed. We then gently filled the bladder with 250 cc of methylene blue/normal saline solution. No leaks were identified. We then allowed everything to flush back out and irrigated out the pelvis and the abdomen. Clear returns were present. We again looked down the pelvis to be sure there were no other injuries. He currently has a no. 18-French three-way catheter in place. Instead of placing a suprapubic tube, I think it would be easier to manage him with this Foley catheter, and we will plan to take this out in 2 to 3 weeks’ time. He will be allowed to go home with a leg bag. We then pulled down the omentum over the small bowel. We closed the fascia with no. 1 looped PDS in a running fashion. The wound was irrigated out. The skin was then closed with staples. Sterile dressings were applied. The patient tolerated the procedure well and went to the recovery room in stable condition.


Related posts:

  1. Integumentary system
  2. Musculoskeletal system
  3. Pathology and laboratory
  4. Evaluation and management services

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May 17, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Urinary, male genital, and endocrine systems

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