Benign Prostatic Hyperplasia
As per Mayo Clinic, “Benign prostatic hyperplasia (BPH) is a health issue that becomes more common with age. It’s also called an enlarged prostate. The prostate is a small gland that helps make semen. It’s found just below the bladder. And it often gets bigger as you get older. An enlarged prostate can cause symptoms that may bother you, such as blocking the flow of urine out of the bladder. It also can cause bladder, urinary tract, or kidney problems.”
Code selection for BPH can be found by searching the ICD-10-CM Alphabetic Index for Enlargement/prostate or Hyperplasia/prostate. For coding BPH, the 4th character identifies whether the patient has urinary obstruction and other urinary tract symptoms. There is a coding directive to “Use additional code to identify symptoms, when specified” under N40.1. Normally, we would not code for symptoms when a definitive disease is confirmed. In this case, the instructional note provides guidance that a code for the symptoms is required.
Q: A 51-year-old male patient diagnosed with benign prostatic hyperplasia presents with urinary urgency. What ICD-10-CM coding is reported?
A: N40.1, R39.15. Rationale: We see the patient had been diagnosed with Benign Prostatic Hypertrophy and urgency, which is a symptom of this condition. We look at the ICD-10-CM Alphabetic Index for Hypertrophy, then prostate, which directs us to Enlargement, enlarged, prostate. We see Enlargement, enlarged/prostate/with lower urinary tract symptoms (LUTS) leads us to N40.1. As we navigate to the Tabular List, N40.1 has an instructional note to “Use additional code for associated symptoms, when specified.” We will use ICD-10-CM code R39.15 to report the urinary urgency. Remember, because code R39.15 is listed as an additional code, we would not report this as the primary code.
Reference: 2024 ICD-10-CM code book
