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Gross hematuria

Denise Posted Tue 02nd of February, 2016 12:24:04 PM

Need diagnosis code(s) for Cystoscopy with evacuation of blood clots and fulguration of the prostate (CPT 52001-59, 52214) for Gross hematuria, BPH.
At cysto pt was found to have MULTIPLE CLOTS in the bladder which were evacuated with Ellik device. Bladder neck and prostate vasculature that was bleeding was fulgurated with rollerball cautery. OP NOTE:...pt has BLEEDING OFF PROSTATE with very friable vessels that bleed easily, ENLARGED PROSTATE WITH OBSTRUCTION, some median hypertrophy and VASCULARITY.
In ICD-10 under N42.1 HEMORRHAGE of prostate is excluded with N40.__ enlarged prostate (Excludes #1 note).
A. Should I use I86.8 (prostate varices) and R31.0 gross hematuria to show the clots/bleeding off prostate???? along with N40.1?
B. Principal diagnosis??

SuperCoder Answered Wed 03rd of February, 2016 04:38:37 AM

Yes, all the three codes I86.8, R31.0, N40.1 seem appropriate for the given situation. However, it is not clear from the information provided, that for which major problem the patient underwent the procedure. If you need to know the principal diagnosis code, then please provide me with the details of the case. Thanks!!

Denise Posted Wed 03rd of February, 2016 11:30:12 AM

Pt complained of gross hematuria over the past month, seeing actual blood clots. Urinalysis positive for UTI and TNTC RBCs. Treated with antibiotic for the UTI and hematuria somewhat cleared. He is now having recurrent bleeding with CT scan giving no etiology for the GROSS HEMATURIA. Pt has BPH (very large prostate on CT scan) with improvement of urinary frequency and nocturia on Proscar.
Diagnosis on operative report was 1. Gross hematuria 2. BPH

SuperCoder Answered Thu 04th of February, 2016 05:24:26 AM

In this case I would suggest code R31.0 Gross hematuria to be the principal diagnosis. You may find the following article (page 96) useful for reference:
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-10-CM-Guidelines.pdf

Thanks!!

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