ICD-10 Coding for Prostatic Hyperplasia(N40.0, N40.1)
Complete ICD-10-CM coding and documentation guide for Prostatic Hyperplasia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Prostatic Hyperplasia
N40-N40.3Primary Range
Hyperplasia of prostate
This range includes codes for benign prostatic hyperplasia with and without lower urinary tract symptoms.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N40.0 | Benign prostatic hyperplasia without lower urinary tract symptoms | Use when BPH is present without any documented lower urinary tract symptoms. |
|
| N40.1 | Benign prostatic hyperplasia with lower urinary tract symptoms | Use when BPH is present with documented LUTS. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for prostatic hyperplasia with LUTS
Essential facts and insights about Prostatic Hyperplasia
Primary ICD-10-CM Codes for prostatic hyperplasia
Decision Criteria
clinical Criteria
- No LUTS present
Applicable To
- Asymptomatic prostatic enlargement
Excludes
- BPH with LUTS (N40.1)
Clinical Validation Requirements
- Digital rectal exam showing enlarged prostate
- PSA level within normal range for BPH
Code-Specific Risks
- Misuse when LUTS are present but not documented
Coding Notes
- Ensure no LUTS are documented before using this code.
N40.1 - Benign prostatic hyperplasia with lower urinary tract symptoms
Use when BPH is present with documented LUTS.
Applicable To
- BPH with LUTS such as nocturia, weak stream
Excludes
- BPH without LUTS (N40.0)
Clinical Validation Requirements
- Documented LUTS such as frequency, urgency, weak stream
- IPSS score indicating moderate to severe symptoms
Coding Notes
Ensure LUTS are explicitly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Urinary retention, unspecified
R33.9Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Prostatic Hyperplasia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N40.0.
Impact
Clinical: Inaccurate symptom tracking., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Train staff on documentation requirements., Use templates to ensure completeness.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure LUTS are documented in the patient's record.
Impact
Failure to document LUTS when coding N40.1.
Mitigation Strategy
Regular audits and staff training.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Prostatic Hyperplasia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Prostatic Hyperplasia
Use these documentation templates to ensure complete and accurate documentation for Prostatic Hyperplasia. These templates include all required elements for proper coding and billing.
BPH with LUTS
Specialty: UrologyRequired Elements
- Patient symptoms
- IPSS score
- PSA level
- Uroflowmetry results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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