ICD-10-PCS CODING 2022 - CHAPTERS 17-18 - CONCEPT REVIEW Part 3.docx

PREOPERATIVE DIAGNOSIS: Benign prostatic hypertrophy
POSTOPERATIVE DIAGNOSIS: Benign prostatic hypertrophy
PROCEDURES PERFORMED:
1. Cystoscopy
2. EVOLVE laser transurethral resection of the prostate
3. Electrosurgical transurethral resection of the prostate
SPECIMENS: Prostate chips
INDICATIONS: This is a 66-year-old gentleman with a long-standing history of lower
urinary tract symptoms linked to benign prostatic hypertrophy. He has undergone a trial
of medical therapy without substantial improvement in symptoms. He presents for
definitive treatment of the same.
DETAILS OF PROCEDURE: Informed consent was obtained, during which the risks,
benefits, and alternatives to the procedure were explained in detail. The patient agreed
to proceed.
The patient was taken to the operating room, where general anesthesia was induced.
He was placed in the dorsal lithotomy position and prepped and draped in the usual
standard sterile fashion. A 22 French cystoscope sheath with obturator was lubricated
and inserted into the urethral meatus. The 30-degree lens with laser bridge was inserted
through the scope and the prostate was inspected. It was notable for a large protruding