Problem
Review each case scenario, assign, and properly sequence the ICD-10-CM diagnosis and ICD-10-PCS procedure codes. Be aware that when an answer consists of more than one code, there will be an answer blank for each code.
This is a 62-year-old male patient seen in the office because of urinary difficulty. The patient noticed that he had to strain when he had to urinate. He has been having this problem off and on during the past year. Also, sometimes he has to move his bowels when he urinates because of the strain. His urinary stream is very slow. He has no history of dysuria or hematuria. His past history reveals that he has high blood pressure, and he is taking medication for that with occasional Valium. He also has been complaining of some pain in the lower back at the area of the coccyx bone. On his physical examination, the abdomen was soft with no tenderness or mass palpable. He has normal external genitalia with a rectally grade III smooth prostate gland. The patient's urological workup was done as an outpatient, and this showed an essentially normal upper urinary tract and enlarged prostate. He is admitted to the hospital for transurethral resection of the prostate (TURP). On the day of admission, under general anesthesia, transurethral resection of the prostate (via artificial opening) to trim away excess prostate tissue only was performed. Postoperatively, the patient did well. When his catheter was removed, he was able to void well without any difficulty. The pathology report revealed benign prostatic hyperplasia. Because of a tender coccyx bone, he did have several x-rays, which were negative. The pain was improved by injecting Aristocort and Novocain into this area. The patient's hypertension medication was continued. The patient was discharged and will be seen in the office in 3 weeks.
DISCHARGE DIAGNOSES:
Benign hyperplasia of the prostate with urinary obstruction
Straining to void
Poor urinary stream
Coccygodynia
Hypertension
PROCEDURE:
Transurethral resection of the prostate.