Question

12. This gentleman has worsening bilateral hydronephrosis. He did not have much of a post void residual on his bladder scan. He is taken to the operating room to have a bilateral cystoscopy and retrograde pyelogram. The results come back as gross prostatic hyperplasia with urinary retention as the cause of the hydronephrosis

Answer 1

52005, N40.0 and N13.39

Step-by-step explanation:

• 52005 identifies a cystoscopy with bilateral ureteral catheterization and injection of dye for a retrograde pyelogram (x-ray of the kidney and ureter.
• N40.0 is the correct diagnosis code for hyperplasia of prostate. Although the patient has hydronephrosis caused by the prostate problem, there is no mention of lower urinary symptoms.
• N13.39 indicates "other" hydronephrosis. Hydronephrosis in this case is caused by enlargement of the prostate, which causes urinary retention with backup of urine to the kidneys.