General Surgery Coding Alert

Question: Our surgeon performed a TURP procedure. When the patient came in for follow-up care, what diagnosis code should we use - Z90.79?

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Answer: Code Z90.79 (Acquired absence of other genital organ(s)) is probably not the best choice, partly because transurethral resection of prostate (TURP) procedure doesn't typically result in removal of the entire prostate gland.

The diagnosis you should report depends on the diagnosis following the TURP surgery, and the reason the patient presents for the office visit. For instance, if the patient presents during the global period and the pathology report from the surgery resulted in a diagnosis of prostate cancer, you should list first C61 (Carcinoma of prostate gland).

If the patient presents outside of the global period for something related to the surgery but not the cancer, such as treating a scar from the procedure, you mightlist a code such as Z48.816 (Encounter for surgical aftercare following surgery on the genitourinary system).