BPH ICD 10 Codes: N40.0 vs. N40.1 and LUTS

ICD-10 CM Selection Guidelines for BPH

Documented BPH and urinary symptoms

Find an active BPH diagnosis and urinary symptoms in the signed encounter record. Make sure you review the history and the assessment together. In the assessment, a provider may document LUTS, and on a separate line, may document the prostate is benign and enlarged. If the history states that a patient is experiencing BPH symptoms, and a diagnosis of enlarged prostate is documented, you can assume the two are linked. Sometimes, an intake checkbox or an imported problem-list entry may need clarification.

Refer to I.A.15 in the Official Guidelines for the “with” convention. In ICD-10-CM, there is an assumption of association when the classification links conditions with an applicable “with” entry. The Alphabetic Index relates enlarged prostate to LUTS. If the symptoms and the diagnosis of enlarged prostate are documented as current, you can assume the association exists even if the note does not contain the words due to.

Follow a documented statement stating the patient’s urinary symptoms are not associated with BPH.

It is good practice to create a rule to flag all separate mentions of BPH and nocturia, but this may lead to unnecessary queries. The same is true for all separate mentions of nocturia and BPH. You should evaluate the documentation, especially if the history and the assessment are not in agreement.

BPH without symptom detail

The correct choice of code when the provider reports enlarged prostate and BPH without lower urinary tract symptoms is typically N40.0. However, when BPH and LUTS are both specified in the clinical evaluation, N40.1 may be used even when the individual symptoms are not specified. Choosing the right diagnostic code and coding the symptoms separately are independent processes.

A high PSA level, an ongoing prescription, or other details related to the prostate need to be considered as well while analyzing the medical record. The coding must be done based on what the provider has recorded about the patient’s diagnosis and symptoms. Controlled LUTS that continue to be included in the clinical BPH assessment need to be coded when justified by documentation. Medical coding services can help identify any omissions, conflicting documentation, and whether a compliant provider inquiry needs to be made before filing claims.

Symptoms with an uncertain outpatient diagnosis

An outpatient note may state that the patient has a weak stream, and the note may also list BPH as a potential cause. Based on the Official Guidelines, IV. Findings, Symptoms and Other Reasons for the Encounter, report the reason for the encounter at the most supportable level of certainty. Although the diagnosis may be uncertain, the documentation of a symptom supports the need for a clinical evaluation. It is proper to code the symptom based on the reason for the encounter, rather than the diagnostic code that may reflect the potential cause.

Additional Codes for Lower Urinary Tract Symptoms

LUTS includes storage complaints, such as urgency or frequency, and voiding complaints, such as hesitancy or a weak stream. The Tabular List directs coders to add codes for associated symptoms when specified under both N40.1 and N40.3. Match each reportable finding to the documented term. There is no set number of additional codes that belongs on every claim.

Retention, obstruction, and incomplete emptying

These terms relate to different codes. In the absence of a post-void residual measurement, a patient’s report of “I don’t feel empty” would be documented and reported as R39.14. Post-void residual measurements tell you how much urine was left in the bladder at the time of testing. Whether the record supports retention also depends on the clinician’s interpretation and the diagnosis. A measurement is a volume by itself; the coding instruction does not set a universal threshold for assigning R33.8.

In the case of documented retention related to BPH, N40.1 and R33.8 are reported together. If the urinary tract obstruction is attributed to BPH, then N40.1 and N13.8 are reported together. Both codes R33.9 and R33.8 direct you to report the causal condition first. Retention unspecified is reported as R33.9, only when the record supports this.

The order of paired diagnoses is a separate concern from which diagnosis leads the entire claim. In the case of a prostate condition which is present but not the main reason for a visit, the prostate condition may be present but not first listed. The tabular list gives guidance as to which diagnosis should come first. Consider the reason for encounter as well.

Documentation That Supports the Code and the Service

The signed record should include the following.

• Evidence of the assessment.
• Example: BPH with urinary urgency and sensation of incomplete emptying. Bladder scan ordered to assess residual urine.
• Findings of the assessment.
• Example: Scan shows 120cc of residual urine.
• The signed record should also include.
• Evidence of the assessment.
• Example: Prostate nodule discovered by ultrasound.
• Test or Procedure indication.
• Example: Bladder scan to assess urinary retention.
• Important findings.
• Example: Urinary tract infection.
• Assessment and Plan.

If a decision to perform a procedure or order a test is based on an IPSS, a PSA, or a digital rectal exam, a N40.1 would still be an appropriate code. The diagnosis code N40.1 has no specific requirements with regard to the procedure or test. If there is a policy requirement for a specific test or procedure, that requirement must be independently evaluated and reported.

Request for Clarification for Inconsistent Information

If the provider’s history states weak stream and the assessment states BPH without LUTS, a non-leading query can ask the provider to reconcile the clinical data and information that pertains to the code. A good query is usually short.

The history states there was a weak urinary stream. The assessment states there was no LUTS and benign prostatic hyperplasia (BPH). Could you clarify your assessment of weak stream and its relationship to the condition of the prostate if known?

The provider can identify a relationship, give a different answer, or state the relationship is not determined. Keep the clarification with your organization’s documentation process. Good query resolve a discrepancy in the chart and leave clinical judgment to the provider.

BPH, Prostate Cancer and Excludes Notes

Excludes1 Benign Neoplasm of the Prostate

The category N40 has an Excludes1 note with respect to D29.1 (benign neoplasm of the prostate). Check the documented diagnosis before assigning either code. A physician diagnosis of benign prostatic hyperplasia (BPH) and a physician diagnosis of a benign neoplasm occur at different locations in the Index though both are benign conditions.

The general Excludes1 rule states that if conditions coexist, they cannot both be coded. The Official Guidelines state that there are rare, clear-cut exceptions to this rule. If both conditions are documented and their relationship is unclear, query the provider. Also examine the Excludes1 notes that are associated with the other condition. For example, the Excludes1 note for prostatic congestion and hemorrhage is located at N42.1 and refers to the N40 family.

Excludes2 and active prostate cancer

The Excludes2 note for C61 in the N40 category indicates that both codes may be assigned when prostate cancer and BPH are documented separately and are clinically relevant. For example, if the encounter is documenting active cancer of the prostate and C61 is first listed, then if BPH and associated nocturia is managed by a urologist, N40.1 and R35.1 may be assigned if supported by the record.

In an outpatient setting, if prostate cancer is confirmed, C61 would be assigned. If the provider is evaluating an elevated PSA and the workup is still in progress, R97.20 may be assigned. Z12.5 would be assigned if the encounter is preventive prostate cancer screening. There are different indications for a screening and a diagnostic service and, therefore, should be coded separately.

Prostatitis is in the N41 family. If there is a UTI documented, assign the appropriate ICD-10 code for UTI based on the documented site. BPH may be assigned if it is being assessed and meets the coding requirements. If there are urinary symptoms, and the cause is determined to be an infection or other condition, coding for that condition should be assigned, and BPH should be assigned if supported by the documentation.

This provides guidance on how diagnosis selection impacts assignment of related CPT® codes and associated billing.

Resolved BPH and Follow-Up Coding

Z87.438 can be used to add a personal history of resolved benign prostatic hyperplasia (BPH) if the provider documents that the condition is resolved and the patient is not receiving any treatment for it.

Z87.430 describes a history of prostatic dysplasia, which is a different diagnosis, and should not be used to denote resolved BPH. If the reason for the visit is to perform a follow-up examination to a completed treatment and the condition has resolved, review Z09 first, followed by the appropriate personal history code described under Z87.

Read past the name of the surgery reported. An operative report describes that a surgery occurred. A provider’s current assessment determines if BPH is still present, if LUTS are still present, and if a personal history code is warranted. A patient whose BPH is still managed as an active condition is in the N40 family. Report any relevant post-procedural status code only if the documentation supports the status and meets the reporting criteria.

Worked Examples from Urology Coding

The examples are fictional and illustrate cases that occur in outpatient chart review.

BPH and Nocturia in Different Parts of the Note

An urologist assessed BPH and created a plan to manage it. Nocturia and weak stream were documented as symptoms in the visit as part of the assessment with no counter cause documented. Report N40.1, R35.1, and R39.12. Index linkage justifies the combination and the additional codes describe the symptoms. Verify the symptoms are part of the current assessment before using this approach to a copied history.

Reason for Catheter Placement

The provider assesses urinary retention due to enlarged prostate, documents catheter placement. The charge worksheet lists unspecified retention as the first diagnosis. Report N40.1 followed by R33.8 for the documented pair. The causal condition leads because of the Code First instruction. Review the procedure line separately to point to the diagnosis that supports the service.

Nodular prostate with urge incontinence

The urologist assesses nodular prostate with urge incontinence and addresses both in the plan. Report N40.3 and N39.41. The diagnosis code N40 is dominant and controls the type of leakage, and N39 is non-dominant and controls the additional code. A template that defaults every symptomatic enlargement to N40.1 would miss the wording of this assessment.

BPH with a separate cause of Urinary Urgency

The clinician manages acute cystitis with hematuria and states the urgency is due to the infection. Another part of the same visit documents the assessment of BPH without LUTS. Report N30.00 and N40.0 for this case. The clinician identified the cause of urgency and the symptom was part of the cystitis. The BPH code reflects the separate prostate condition.

Possible Prostate Diagnosis Symptom Workup

The evaluation reveals reduced urine flow with either benign prostatic hyperplasia or urethral stricture and the provider requests tests to examine the symptom. In the present case, use code R39.12 to document the reason for the examination. When the cause has been identified, apply the diagnosis to the corresponding encounter.

Effective communication between the clinical and medical billing service teams should involve the reason for the examination, level of diagnostic certainty, history, and services rendered.

BPH Claim Review and Denial Prevention

Diagnosis and Procedural Indications

For a paid claim, the diagnosis indicates a service line for the reason for the service. An example would be managing BPH without LUTS, and the physician performs a diagnostic cystourethroscopy, CPT 52000, to evaluate gross hematuria. If the record supports both of these, then N40.0 can be listed on the claim while the service line for the cystourethroscopy is for R31.0, Gross Hematuria, per the applicable claim instructions. The indication for the scope is the reason for the service and drives the service line.

A non-imaging bladder ultrasound to measure Post Void Residual (PVR), CPT 51798, should also be documented. One indication would be transurethral resection of the prostate (TURP), CPT 52601. Ensure that the documented operation and the technique performed support the code. If the condition is supported, N40 can be listed on the claim. Again, the service performed must also meet all coverage, medical necessity and documentation requirements.

Check national coverage rules and billing and coding articles for relevant Medicare contractors’ local coverage determinations (LCDs). For example, the waterjet ablation LCD from one Medicare contractor discusses acceptable clinical criteria including prostate volume and symptom scores. This is a policy for a specific service and jurisdiction. For Medicare Advantage or commercial coverage, review the relevant plan’s criteria and authorization guidelines.

Separate Evaluation and Procedure Work

A minor procedure or diagnostic service can support modifier 25 when the record documents significant, separately identifiable E/M work beyond what is included in the procedure and the rules for the E/M service and procedure are satisfied. In this case, the provider may evaluate urinary symptoms and make a management decision regarding that symptom. Review the note and make sure it meets the above requirements before adding the modifier.

Two Procedures

For two procedures performed at the same visit, check the applicable procedure-to-procedure edit and modifier indicator. A distinct-service modifier is only appropriate in cases where the edit allows it and the conditions in the record substantiate it. If the scrubber flags an edit for the second service, review the code pair and the services performed to determine if the service was coded as one or both of the procedures, or if it was documented and/or performed as a distinct service.

Common mistakes to catch before submission

Rejections, Denials, and Audits

Invalid codes in the claim acknowledgment trigger validation and correction using the rejection process. A denial is accompanied by reading of the remittance advice with the details of the claim adjustment reason and remark code. In case of a medical necessity denial, compare the denied service line, its pointer, the clinical indications, and the payer guidelines. If the submission was correct, and it can be covered under the plan according to the record, use the appeals or documentation procedure set by the payer.

For an audit, select some cases of BPH that have been paid, denied, or rejected. Note from which of the four areas did the issue arise – from the provider note, coding, claim processing, or payer coverage evaluation. If you are monitoring denials and comparing denial lines against adjudication lines for the same payer and procedure code, then changes in N40.0 and N40.1 are an indication to sample the charts. The case mix and the actual notes will tell about coding issues.