Find comprehensive information on Prostatic Hypertrophy, including BPH diagnosis, ICD-10 codes (N40), clinical documentation improvement tips, medical billing guidelines, and treatment options. Learn about benign prostatic hyperplasia symptoms, enlarged prostate causes, and effective management strategies for healthcare professionals. This resource provides valuable insights for accurate coding and optimal patient care related to prostatic enlargement and lower urinary tract symptoms LUTS.
Also known as
Diseases of male genital organs
Covers various male reproductive system disorders, including prostatic hypertrophy.
Incontinence
Includes urinary incontinence, a common symptom of prostatic hypertrophy.
Ill-defined and unknown causes
May be used for unspecified symptoms related to prostatic hypertrophy if needed.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the prostatic hypertrophy symptomatic?
Yes
With lower urinary tract symptoms (LUTS)?
No
Is the hypertrophy incidental?
When to use each related code
| Description |
|---|
| Enlarged prostate, non-cancerous |
| Prostate inflammation/infection |
| Bladder outlet obstruction |
Using unspecified codes (e.g., N40.9) when a more specific diagnosis for prostatic hypertrophy is documented, impacting reimbursement and data accuracy.
Lack of proper clinical documentation to support the diagnosis of BPH, leading to coding errors and potential denials for medical necessity.
Incorrectly coding related conditions like urinary retention (R33.8) as complications of BPH when they exist independently, inflating case complexity.
Patient presents with symptoms suggestive of benign prostatic hyperplasia (BPH), also known as an enlarged prostate. Presenting complaints include lower urinary tract symptoms (LUTS) such as weak urinary stream, hesitancy, straining to void, intermittency, incomplete emptying, nocturia, urinary urgency, and urinary frequency. The patient denies dysuria, hematuria, and fever. Digital rectal examination (DRE) revealed a uniformly enlarged, smooth, and non-tender prostate. Prostate-specific antigen (PSA) levels were measured and will be reviewed when available. Differential diagnoses include prostate cancer, urinary tract infection (UTI), and bladder outlet obstruction (BOO). Assessment includes benign prostatic hypertrophy (BPH) with associated lower urinary tract symptoms. Plan includes lifestyle modifications such as limiting fluid intake before bedtime, avoiding caffeine and alcohol, and timed voiding. Pharmacological management may be considered with alpha-blockers or 5-alpha reductase inhibitors. Further evaluation with uroflowmetry and post-void residual (PVR) measurement may be indicated. Patient education provided regarding the nature of BPH, treatment options, and potential complications. Follow-up scheduled in four weeks to assess symptom improvement and discuss further management if necessary.