ICD-10 Coding for Benign Prostatic Hypertrophy with Urinary Retention(N40.1, R33.8)
Complete ICD-10-CM coding and documentation guide for Benign Prostatic Hypertrophy with Urinary Retention. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Benign Prostatic Hypertrophy with Urinary Retention
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| N40.1 | Benign prostatic hyperplasia with lower urinary tract symptoms | Use when BPH is confirmed with LUTS and urinary retention is present. |
|
| R33.8 | Other retention of urine | Use when urinary retention is secondary to BPH. |
|
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 BPH with urinary retention
Essential facts and insights about Benign Prostatic Hypertrophy with Urinary Retention
Primary ICD-10-CM Codes for benign prostatic hypertrophy with urinary retention
Decision Criteria
clinical Criteria
- Presence of LUTS and urinary retention confirmed by tests
documentation Criteria
- Detailed documentation of symptoms and test results
Applicable To
- BPH with LUTS
- BPH causing urinary obstruction
Excludes
- Prostate cancer
- Neurogenic bladder
Clinical Validation Requirements
- Post-void residual >300 mL on two occasions
- IPSS score ≥8
- PSA <4 ng/mL
Code-Specific Risks
- Incorrectly coding without LUTS documentation
- Omitting urinary retention details
Coding Notes
- Ensure documentation specifies LUTS and links retention to BPH.
R33.8 - Other retention of urine
Use when urinary retention is secondary to BPH.
Applicable To
- Urinary retention not otherwise specified
Excludes
- Drug-induced retention
Clinical Validation Requirements
- Documentation linking retention to BPH
- Exclusion of neurogenic causes
Coding Notes
Ensure retention is documented as secondary to BPH.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other retention of urine
R33.8Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Benign Prostatic Hypertrophy with Urinary Retention to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code N40.1.
Impact
Clinical: May lead to inadequate treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Include detailed symptom descriptions, Use structured templates
Impact
Reimbursement: May lead to incorrect DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Reduces specificity and accuracy of data.
Mitigation Strategy
Use R33.8 when BPH is the confirmed cause of retention.
Impact
Failure to sequence N40.1 before R33.8
Mitigation Strategy
Use coding guidelines to ensure proper sequencing.
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 Benign Prostatic Hypertrophy with Urinary Retention, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Benign Prostatic Hypertrophy with Urinary Retention
Use these documentation templates to ensure complete and accurate documentation for Benign Prostatic Hypertrophy with Urinary Retention. These templates include all required elements for proper coding and billing.
BPH with urinary retention in a urology clinic
Specialty: UrologyRequired Elements
- Patient history
- Physical examination findings
- Diagnostic test results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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