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.