Question

99.OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Recurrent carcinoma of the prostate
POSTOPERATIVE DIAGNOSIS: Recurrent carcinoma of the prostate
PROCEDURE PERFORMED: Cryoablation of the prostate
CLINICAL NOTE: This is a 53 year old gentleman who has undergone radiation therapy for adenocarcinoma of the prostate. Unfortunately, he developed problems again and underwent a needle biopsy, and recurrence of his cancer was found. Options were discussed with the patient, and he has opted to proceed with cryoablation. He has been told of the risk of incontinence and possible rectal injury. He understands and still chooses to proceed with the surgery. PROCEDURE: The patient was given a general endotracheal anesthetic and was prepped and draped in the lithotomy position. An 18-French Foley catheter was placed in the bladder. A transrectal probe was introduced. Prostate volume was returned at 27.5 g. A six-probe freeze was selected. Using quick stick method, sheaths were placed using ultrasound guidance. Following placement of the sheaths, temperature probes were then placed in the left and right neurovascular bundles, apex, external sphincter, and Denonvilliers fascia. A two-cycle probe freeze was performed. The first cycle was a very rapid freeze, and the second cycle was a more prolonged freeze. The external sphincter temperature never reached less than 0° C. The freeze was monitored both digitally and radiographically with ultrasound. The probes were then withdrawn after the full thaw. Two active thaw cycles were undertaken. The perineal incisions were then closed with 3-0 plain catgut subcuticular sutures. The catheter was left in. The patient tolerated the procedure well and was transferred to the recovery room in good condition.
CPT Code(s): ______
ICD-10-CM Code(s): ______ , ______

Answer 1

Prostate cancer is assigned to ICD-9-CM diagnosis code 185. Carcinoma in situ of the prostate is classified to code 233.4, and a benign neoplasm of the prostate goes to code 222.2. If it’s documented that the neoplasm is of the seminal vesicles, assign codes 187.8 for malignant cancer, 233.6 for carcinoma in situ, and 222.8 for benign neoplasm.

Prostatic intraepithelial neoplasia (PIN) is a premalignant condition and a common precursor to prostate cancer. There are three levels of PIN: PIN 1 and PIN 2 are classified to code 602.3, Dysplasia of prostate. PIN 3 is indexed to code 233.4, Carcinoma in situ of prostate

Malignant prostate cancer may metastasize to other sites, including the bladder or urethra (198.1), bone (198.5), intrapelvic lymph nodes such as iliac or sacral (196.6), intra-abdominal (periaortic) lymph nodes (196.2), or the seminal vesicles (198.82).

Malignant neoplasm of prostate. C61 is a billable/specific ICD-10-CM code