Benign prostatic hyperplasia, also known as BPH, is an enlarged prostate. The prostate goes through two main growth cycles during a man’s life. The first occurs early in puberty when the prostate doubles in size. The second phase of growth starts around age 25 and goes on for most of the rest of a man’s life. BPH most often occurs during this second growth phase.
As the prostate enlarges, it presses against the urethra. The bladder wall becomes thicker. One day, the bladder may weaken and may not be able to empty fully, leaving some urine in the bladder. Narrowing of the urethra and urinary retention – not able to empty the bladder fully – cause many of the problems of BPH. BPH is benign. This means it is not cancer. It does not cause or lead to cancer. But, BPH and cancer can happen at the same time. BPH is common. About half of all men between ages 51 and 60 have BPH. Up to 90 percent of men over age 80 have it.
The severity of symptoms in people who have prostate gland enlargement varies, but symptoms tend to gradually worsen over time. Common signs and symptoms of BPH include frequent or urgent need to urinate, increased frequency of urination at night, difficulty starting urination, weak urine stream or a stream that stops and starts, dribbling at the end of urination, and the inability to completely empty the bladder. Less common signs and symptoms include urinary tract infection, inability to urinate, and blood in the urine. The size of your prostate doesn’t necessarily determine the severity of your symptoms. Some men with only slightly enlarged prostates can have significant symptoms, while other men with very enlarged prostates can have only minor urinary symptoms. In some men, symptoms eventually stabilize and might even improve over time.
There are many options for treating BPH. You and your doctor will decide together which treatment is right for you. Mild cases may need no treatment at all. In some cases, minimally invasive procedures (surgery without anesthesia) are good choices. And sometimes a combination of treatments works best. The main types of treatments for BPH are active surveillance, prescription drugs, and invasive surgery. If your BPH only requires active surveillance, your BPH will be closely watched but not actively treated. Prescription drugs include alpha-blockers, 5-Alpha reductase inhibitors, combined therapy, and phytotherapy. Minimally invasive or less invasive surgeries require only tiny cuts or no cuts to the body. In severe cases of BPH, or when other options fail, more invasive surgery is recommended.
In addition to diagnostic codes, ICD-10 also provides codes for various treatment options available for BPH. These codes enable healthcare providers to accurately document the procedures performed and ensure proper reimbursement for the services rendered. Proper coding of BPH treatment options also aids in tracking outcomes, contributing to evidence-based practices and quality improvement initiatives.
One commonly performed procedure for BPH is transurethral resection of the prostate (TURP). This surgical intervention involves removing excess prostate tissue to relieve urinary symptoms. The ICD-10 procedure code for TURP is 0VB00ZZ. Other treatment options for BPH, such as medication management or minimally invasive procedures, also have specific codes that healthcare providers should be familiar with to accurately document the care provided.
ICD-10 codes are alphanumeric codes used to classify and categorize diseases, conditions, and procedures in healthcare settings. When it comes to diagnosing BPH, healthcare providers utilize specific ICD-10 codes to accurately represent the condition. These codes serve as a universal language that enables healthcare professionals to communicate the diagnosis effectively, ensuring consistency and accuracy in medical documentation.
The primary ICD-10 code used for BPH diagnosis is N40. This code represents “Enlarged prostate without lower urinary tract symptoms.” It is important to note that this code alone may not suffice in all cases, as additional codes may be required to capture specific details or complications related to BPH. Healthcare providers should familiarize themselves with the various subcategories and combination codes available within the ICD-10 system to accurately capture the nuances of BPH diagnoses.
| ICD-10 Chapter | Codes | Code Description |
|---|---|---|
| 14 | N40.0 | Benign prostatic hyperplasia without lower urinary tract symptoms |
| 14 | N40.1 | Benign prostatic hyperplasia with lower urinary tract symptoms |
| 14 | N40.2 | Nodular prostate without lower urinary tract symptoms |
| 14 | N40.3 | Nodular prostate with lower urinary tract symptoms |
| 14 | N42.83 | Cyst of prostate |
| 14 | C61 | Malignant neoplasm of prostate |
| 14 | D07.5 | Carcinoma in situ of prostate |
| 14 | N42.31 | Prostatic intraepithelial neoplasia |
| 14 | Z87.430 | ersonal history of prostatic dysplasia |
| 14 | Z85.46 | Personal history of malignant neoplasm of prostate |
Accurate and efficient coding is a cornerstone of streamlined healthcare processes. In the realm of BPH management, proper coding practices enable effective communication, improved data accuracy, enhanced patient care coordination, and optimized revenue cycle management. By understanding the nuances of ICD-10 coding for BPH, healthcare providers can navigate the coding system with ease, minimizing errors and maximizing efficiency.
Through continuous learning, utilization of available resources, and potentially outsourcing coding services, healthcare organizations can ensure accurate documentation of BPH diagnoses and treatment options. By doing so, they contribute to delivering high-quality patient care and streamlining healthcare processes in the ever-evolving world of BPH management.
Author: Tonoya Ahmed
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