Find comprehensive information on Prostatectomy, including clinical documentation requirements, medical coding guidelines (ICD-10-CM, CPT), postoperative care, and recovery. Learn about radical prostatectomy, laparoscopic prostatectomy, and robotic-assisted prostatectomy procedures. This resource provides valuable insights for healthcare professionals, medical coders, and patients seeking information on prostate cancer surgery and post-prostatectomy pathology reports. Explore details on complications, side effects, and long-term outcomes following a prostatectomy diagnosis.
Also known as
Surgical operations on prostate
Procedures performed on the prostate gland.
Diseases of male genital organs
Conditions affecting the male reproductive system.
Persons encountering health services
Encounters for aftercare, follow-up, and other health services.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the prostatectomy total or partial?
Total
Open or laparoscopic approach?
Partial
Transurethral resection (TURP)?
When to use each related code
| Description |
|---|
| Prostatectomy |
| Benign Prostatic Hyperplasia |
| Prostate Cancer |
Using unlisted prostatectomy codes when a more specific code exists leads to claim denials and inaccurate data.
Incorrect coding of the surgical approach (retropubic, perineal, laparoscopic) impacts reimbursement and quality metrics.
Failing to code nerve-sparing procedures when performed understates complexity and affects physician profiling.
Patient presents for postoperative follow-up following radical prostatectomy for prostate cancer. The procedure, performed on [Date], was a [Type of prostatectomy: robotic-assisted laparoscopic prostatectomy, open radical prostatectomy, perineal prostatectomy] with [Pelvic lymph node dissection: yes/no]. Preoperative PSA was [Value] ngmL and Gleason score on biopsy was [Gleason Score]. Surgical pathology report indicates [Pathological stage: pTNM staging], with [Surgical margins: positive/negative] margins. Patient reports [Urinary continence status: e.g., complete continence, stress incontinence requiring pads, use of catheter]. He also reports [Erectile function status: e.g., maintains erections sufficient for intercourse, erectile dysfunction requiring medication]. Current medications include [List medications]. Physical examination reveals a well-healing surgical incision with no signs of infection. Digital rectal exam reveals [DRE findings]. Plan includes continued monitoring of PSA, assessment of urinary function and continence management, and discussion of erectile dysfunction treatment options if indicated. Patient education provided regarding potential long-term complications of prostatectomy including urinary incontinence, erectile dysfunction, and anastomotic stricture. Follow-up scheduled in [Duration] for PSA check and continued symptom management. ICD-10 code Z90.89 (Encounter for other specified aftercare following surgery) and CPT code [Appropriate postoperative follow-up code] are appropriate for this encounter. Keywords: Prostatectomy, prostate cancer, robotic prostatectomy, open prostatectomy, perineal prostatectomy, PSA, Gleason score, urinary incontinence, erectile dysfunction, BPH, TURP, postoperative care, surgical margins, pathology, lymph node dissection, ICD-10, CPT, medical billing, coding.