Clinical Data: Medicare patient. Urinary retention.
Gross Description: Received in formalin, labeled as prostate chips – transurethral resection (TURP). Specimen consists of 11.2 grams of tan-pink tissue, and is totally submitted in cassettes A1-A8.
Microscopic Description: 8 H&E slides reviewed microscopically.
Final Diagnosis: TURP - Prostate gland parenchyma with benign hyperplasia. Negative for malignancy.
What are the appropriate CPT and ICD-10 codes for this scenario?
Transurethral resection of prostate (TURP), is a specimen listed in CPT as 88305. Although the CPT code selection appears to be straightforward, coders have been known to incorrectly assign HCPCS code
G0416 to Medicare for TURP specimens. However, per the code descriptor, (Surgical pathology, gross and microscopic examinations for prostate needle biopsy, any method), G0416 is specific to needle core biopsy samples, and not appropriate for TURP specimens.
The pathologic finding of benign hyperplasia is reported as the primary diagnosis code. Alpha Index: Hyperplasia – prostate – with urinary tract symptoms (LUTS) N40.1. The tabular section includes an instructional note directing the coder to also assign R33.8 for the associated symptom of urinary retention. Per the ICD-10 guidelines, instructional notes in the tabular listing provide sequencing instruction are used to alert the coder that an additional code should be reported, and may appear independently of each other or designate etiology/manifestation paired codes.
The ICD-10 codes are broken down as follows:
- N40 is the primary descriptor for enlarged prostate - benign prostatic hyperplasia.
- 4th digit of “1” defines lower urinary tract symptoms (LUTS), and directs the coder to use an additional code for the associated symptoms, when specified.
- R33 is the primary descriptor for retention of urine.
- 4th digit of “8” defines the urinary retention as “Other”, and includes an instructional note to code first, if applicable, any causal condition such as: enlarged prostate (N40.1)
- 2016 CPT Professional Edition Manual (American Medical Association): page 564
- 2016 ICD 10-CM Manual (AMA) Alpha and Tabular: pages 168, 753, and 827
- 2016 ICD 10-CM Manual (AMA) ICD-10 Official Convention Guidelines: page ix