A 71-year-old male patient comes to the hospital after having been previously diagnosed with benign prostatic hypertrophy with urinary obstruction. Due to this condition, the patient is experiencing increased urination, straining during urination, and a continual feeling of fullness after the bladder has Intermediate Medical Coding 2 Intermediate Medical Coding been emptied. The physician performs a cystourethroscopy to examine the condition of the bladder and urethra, and then subsequently performs a UroLift transprostatic implant procedure using three adjustable implants. CPT code(s): __________________________________________ Solution Ans: Urolift implant & codes Step1 : Understanding BPH Symptom & cystoscopy Symptom Index for the patient matches with BPH ( force and frequency of urination etc). To diagnose the cause of BPH an endoscopy of the urinary bladder is needed. This is done via the urethra. It has a special name: cystoscopy. The procedure is carried out using an instrument called a cystoscope. It uses a thin, fibre-optic tube that has a light and camera at one end. Step2 : The UroLift & the 3 Implant This treatment uses a minimally invasive approach to treating BPH. It lifts or holds the enlarged prostate tissue out of the way by using implants so it no longer blocks the urethra. There is no cutting, heating or removal of prostate tissue. Step 3: The CPT code When a surgical or similar procedure like Urolift is done on a patient, a few rules have to be followed. This includes infoming the patient and the related parties about the procedure before perfoming it and getting their conscent in the appropriate manner. This process of informing the patient and all the concerned parties is called CPT. American Medical Association has issed a systematic code to ensure all the details of this procudure are completed with accuracy and precesion. The term CPT stands for \"Current Procedural Terminology\". It contains a set of information which is copyright protected by the American Medical Association. Step 4 : Major Features of CPT 1. CPT describes all tmedical, surgical, and diagnostic services clearly. 2. It is designed to communicate uniform information about medical services and procedures among all parties: physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical sections. This clarity and transparency is very important. 3. It is the service provider’s responsibility to select the most accurate codes to report a patient’s condition and the services they rendered. 4. In this case , the service provider has to provide applicable coding information for the transprostatic implant procedure using the UroLift® System. 5. The patient is likely to have medical coverage . Some payers of this coverage may have unique coding requirements; the service provider has to verify coding with the health plan. Step 5: Sample CPT 1. ICD-10 Diagnosis Coding : N40.1: Enlarged prostate with lower urina.

1. A 71-year-old male patient comes to the hospital after having been previously diagnosed with
benign prostatic hypertrophy with urinary obstruction. Due to this condition, the patient is
experiencing increased urination, straining during urination, and a continual feeling of fullness
after the bladder has Intermediate Medical Coding 2 Intermediate Medical Coding been emptied.
The physician performs a cystourethroscopy to examine the condition of the bladder and urethra,
and then subsequently performs a UroLift transprostatic implant procedure using three adjustable
implants. CPT code(s): __________________________________________
Solution
Ans: Urolift implant & codes
Step1 : Understanding BPH Symptom & cystoscopy
Symptom Index for the patient matches with BPH ( force and frequency of urination etc). To
diagnose the cause of BPH an endoscopy of the urinary bladder is needed. This is done via the
urethra. It has a special name: cystoscopy. The procedure is carried out using an instrument
called a cystoscope. It uses a thin, fibre-optic tube that has a light and camera at one end.
Step2 : The UroLift & the 3 Implant
This treatment uses a minimally invasive approach to treating BPH. It lifts or holds the enlarged
prostate tissue out of the way by using implants so it no longer blocks the urethra. There is no
cutting, heating or removal of prostate tissue.
Step 3: The CPT code
When a surgical or similar procedure like Urolift is done on a patient, a few rules have to be
followed. This includes
infoming the patient and the related parties about the procedure before perfoming it and getting
their
conscent in the appropriate manner. This process of informing the patient and all the concerned
parties
is called CPT. American Medical Association has issed a systematic code to ensure all the details
of this
procudure are completed with accuracy and precesion.
The term CPT stands for "Current Procedural Terminology".
It contains a set of information which is copyright protected by the American Medical
Association.
Step 4 : Major Features of CPT
1. CPT describes all tmedical, surgical, and diagnostic services clearly.

2. 2. It is designed to communicate uniform information about medical services and procedures
among
all parties: physicians, coders, patients, accreditation organizations, and payers for
administrative, financial,
and analytical sections. This clarity and transparency is very important.
3. It is the service provider’s responsibility to select the most accurate codes to report a patient’s
condition
and the services they rendered.
4. In this case , the service provider has to provide applicable coding information for the
transprostatic implant
procedure using the UroLift® System.
5. The patient is likely to have medical coverage . Some payers of this coverage may have
unique coding
requirements; the service provider has to verify coding with the health plan.
Step 5: Sample CPT
1. ICD-10 Diagnosis Coding : N40.1: Enlarged prostate with lower urinary tract symptoms
(LUTS)
2. Physician coding CPT 52441: cystourethroscopy with permanent adjustable single implants
(its cost etc)
CPT 52442: each additional implant (cost etc)
3. Medical Physician Fee: CPT 52441 + 52442 : Deatisl & cost
and so on.
For more details Urolift service providers website can be referred.