AAPC Ch. 12: Urinary System And Male Genital Syste
AAPC Ch. 12: Urinary System and Male Genital Syste
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AAPC Ch. 12: Urinary System and Male Genital System(questions and answers)
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AAPC Ch. 12: Urinary System And Male Genital Syste
Which gland in the male reproductive system is partly muscular and partly glandular?
Prostate
Rationale: The prostate gland is the gland that is partly muscular and glandular.
Where is urine formed?
Kidneys
Rationale: Urine is formed in the renal tubules and empties into the calyces, then ...
aapc ch 12 urinary system and male genital systemquestions and answers
which gland in the male reproductive system is partly muscular and partly glandular
where is urine formed
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AAPC Ch. 12: Urinary System and Male Genital Syste
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AAPC Ch. 12: Urinary System and Male
Genital System
Which gland in the male reproductive system is partly muscular and partly glandular? -
Answer Prostate
Rationale: The prostate gland is the gland that is partly muscular and glandular.
Where is urine formed? - Answer Kidneys
Rationale: Urine is formed in the renal tubules and empties into the calyces, then into
the renal pelvis of the kidney. It then travels through the ureters to the bladder.
A 65-year-old woman diagnosed with a right renal tumor is status post hand-assisted
laparoscopic nephrectomy. Pathology report reveals a definitive diagnosis of renal
oncocytoma. What is the ICD-10-CM code? - Answer D30.01
RATIONALE: Look in the ICD-10-CM Alphabetic Index for Oncocytoma, which directs
you to see Neoplasm, by site, benign. Look in the Table of Neoplasms for Neoplasm,
neoplastic/renal/Benign column D30.0-. In the Tabular List report 5th character 1 for
right kidney. Correct code choice is D30.01.
Mr. Brown presents today with a sudden onset of chills and fever with dull pain in the
flank over the kidneys, which are tender when palpated. He has urgency and frequency
of urination. Diagnosis is acute pyelonephritis. What is the ICD-10-CM code? - Answer
N10
RATIONALE: Acute pyelonephritis is coded N10, unless mention of a lesion of renal
medullary necrosis is documented. Do not use chronic pyelone-phritis because the
documentation clearly states "acute." Look in the ICD-10-CM Alphabetic Index for
Pylonephritis/acute N10. Verify code selection in the Tabular List.
A Urologist examines the urinary collecting system with a cystourethroscope and
removes four bladder tumors by fulguration. Two tumors measured 1.5 cm and the
other two tumors measured 2.5 cm and 3.0 cm. What code(s) should be reported? -
Answer 52235
RATIONALE: Look in the CPT® Index for Fulguration/Cystourethroscopy with/Tumor.
You are referred to 52234-52235, 52240, 52250. When different size bladder tumors
are removed in one surgical session, the code selection is based on the largest tumor
size. In this example, the largest tumor removed is 3.0 cm. Only one code is reported
regardless of the number of tumors removed.
Excision of urachal cyst and an incarcerated umbilical hernia repair were performed on
a six-year-old male. Code the procedure: - Answer 51500
RATIONALE: Umbilical hernia repair codes are reported using CPT® 49580-49587 and
are differentiated by the age of the patient and whether or not the hernia is reducible,
incarcerated or strangulated. A reducible hernia is one that can be reduced to a normal
position. An incarcerated or strangulated hernia is one that cannot be reduced to a
normal position without surgical intervention. The description of CPT® 51500 Excision
of urachal cyst or sinus, with or without umbilical hernia repair includes the umbilical
,AAPC Ch. 12: Urinary System and Male
Genital System
hernia repair. Hernia repair is not reported separately; therefore, CPT® 51500 is the
correct answer. Look in the CPT® Index for Cyst/Urachal/Bladder/Excision 51500.
Patient presents for treatment of multiple condyloma on the penis. The excised diameter
is 0.8cm. Code the procedure. - Answer 54060
RATIONALE: Surgical excision of condyloma(s) of the penis is reported using CPT®
54060. Report this procedure only once because the description includes multiple
condyloma excision during a single/same surgical setting. CPT® 11420 describes
excision of a benign lesion of the genitalia, but is not specific to condyloma and the
diameter of the lesion excision is stated as 0.5 cm or less. CPT® 11421 describes a
benign lesion excised from the genitalia 0.6 cm to 1.0 cm, and would be appropriate had
there not been a clear and concise code for condyloma excision. CPT® 11621
describes a malignant lesion excision and is not reported because there is no
documentation of a malignant lesion excision. Tip: When determining the specific code
to report, the body system or organ should be accessed first, before using the
integumentary codes. Look in the CPT® Index for Condyloma/Penis for the range of
codes.
A circumcision was performed on a newborn using a dorsal penile nerve block for
anesthesia. The provider used a Plastibell for this circumcision. What CPT® code is
reported? - Answer 54150
Rationale: In the CPT® Index, look for Circumcision/Surgical Excision/Neonate 54150,
54160. A Plastibell is a type of device used in a circumcision. Code 54150 is correct.
Modifier 52 is not required; because a dorsal penile nerve block was used.
What modifier is appended to report a bilateral procedure? - Answer B or C
RATIONALE: Depending upon the insurer, either modifier 50 or RT and LT is appended
to the surgical procedure.
To report a repeat procedure by the same physician, what modifier is reported? -
Answer 76
Rationale: Sometimes it is necessary for a physician to repeat a procedure. When this
occurs, modifier 76 is appended.
CASE 1
Preoperative diagnosis: Transitional cell carcinoma in the bladder.
Postoperative diagnosis: Transitional cell carcinoma in the bladder. (This is the
diagnosis to report, since the pre and post-operative diagnoses are the same. The
operative note is consistent with a tumor on the posterior bladder wall. Pathology is not
back yet, but the stated diagnosis is transitional cell carcinoma in the bladder. In the US,
90% of all bladder cancers are transitional cell in origin. This is sometimes referred to as
urothelial carcinoma.)
, AAPC Ch. 12: Urinary System and Male
Genital System
Procedure: Cystoscopy; Excision bladder tumor -1 cm.
Bilateral retrograde pyelogram.
Cytology of bladder.
Anesthesia: General. (Anesthesia, local or general, is usually not reported by the
physician performing the procedure. This information is for documentation quality
purposes only.)
Estimated Blood Loss: 10 cc.
Complications: None.
Counts: Correct.
Indications: The patient is a 58 year-old male status post partial cystectomy for
transitional cell carcinoma of the bladder. He understood the risks and benefits of
today's procedure, and elected to proceed.
Procedure Description: The patient was brought to the operating room, placed on the
operating room table, and placed in the supine position. After adequate LMA anesthesia
was accomplished he was put in the dorsal lithotomy position and prepped and draped
in the usual sterile fashion.
A 21-French rigid cystoscope was introduced through the urethra and a thorough
cystourethroscopy was performed. (The surgery will be performed through a
cystourethroscopy.) A 1 cm tumor was noted on the posterior bladder wall.(This is the
location of the tumor to report as the definitive diagnosis.) The tumor was resected
without complications.
We obtained bladder cytology and performed a retrograde pyelogram, which showed no
filling defects or irregularities.
The bladder was emptied, and lidocaine jelly was instilled in the urethra. He was
extubated and taken to the recovery room in good condition.
Disposition. The patient was taken to the post anesthesia care unit and then discharged
home.
Bilateral Retrograde Pyelogram Interpretation
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