Urology Coding Alert

Compare your answers to the experts’ to figure out where you need work. 

When your urologist writes “ASAP” do you know if he means “as soon as possible” or “atypical small acinar proliferation”? 

Acronyms are commonplace in the healthcare field, but if you and your provider are not on the same page, the results could be disastrous. Take a look at five examples you might see in a urology chart, from Leah Gross, CPC, CUC, coding lead at Metro Urology in St. Paul, Minn., and test your own deciphering skills.

Review the Notes

See if you can quickly figure out what the urologist did in these five notes:

Note 1: 58 y.o. female presents with MUI, SUI > UUI.  We discussed TOT vs. TVT sling, and will proceed with the former.

Note 2:  88 y.o. male with bx results showing HGPIN and ASAP.  Pt also has concerns with increasingly problematic LUTS. He does not feel he can empty.

Note 3:  I operated on a 37 yo female today with severe colic associated with kidney stones.  Did cystoscopy, URS, HLL of 9 mm stone, RPG, and placement of a JJ stent.  Due to the size of the remaining stones, I could not eradicate her of the disease.  Patient is to f/u in clinic to discuss ESWL vs. PCNL.

Note 4: 45 y.o. female here to discuss HRT.  I have reviewed her estradiol, free and total testosterone, TSH and DHE-A results and believe she is a good candidate for this.

Note 5: 28 y.o. male with CBAVD here to discuss his options.  I have recommended PESA and if it fails, converting to TESE.

Compare Your Answers

Answer 1: Translated into real-world terminology, the first example says the urologist saw a 58-year-old (y.o.) female who presented with mixed urinary incontinence (MUI), stress urinary incontinence (SUI), and urge urinary incontinence (UUI). “The > means the stress component is greater than the urge component,” Gross explains.

The urologist and patient discussed transobturator tape (TOT) versus transvaginal tape (TVT) sling treatment options and decided to use the former.

Answer 2: In the second example, an 88-year-old (y.o.) male patient sees the urologist. His biopsy (bx) results showing high-grade prostatic intraepithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP). The patient also has concerns with increasingly problematic lower urinary tract symptoms (LUTS). He feels he cannot empty his bladder.

Answer 3: The urologist in the third example states that he operated on a 37-year-old (y.o.) female with severe colic associated with kidney stones. He performed s cystoscopy, ureterorenoscopy (URS), holmium laser lithotripsy (HLL) of a 9 mm stone, a retrograde pyelogram (RPG), and placement of a double-J (JJ) stent.  Due to the size of the remaining stones, he could not eradicate the patient of the disease. Therefore, the urologist asked the patient to follow up (f/u) in clinic to discuss an extracorporeal shockwave lithotripsy (ESWL) versus percutaneous nephrostolithotomy (PCNL).

Answer 4: In the fourth note, a 45-year-old (y.o.) female saw the urologist to discuss hormone replacement therapy (HRT). The doctor reviewed her estradiol, free and total testosterone, thyroid stimulating hormone (TSH) and dehydroepiandrosterone sulfate (DHE-A) results and believed she would be a good candidate for the treatment. 

Answer 5: In the final scenario, a 28-year-old (y.o.) male patient with congenital bilateral absence of vas deferens (CBAVD) saw the urologist to discuss his options. The provider recommended the patient undergo percutaneous epididymal sperm aspiration (PESA). If the PESA failed, the urologist planned to convert to a testicular sperm extraction (TESE).