ICD-10 Coding for History of Benign Prostatic Hypertrophy(N40.0, N40.1, Z87.44)
Complete ICD-10-CM coding and documentation guide for History of Benign Prostatic Hypertrophy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Benign Prostatic Hypertrophy
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 LUTS. |
|
| N40.1 | Benign prostatic hyperplasia with lower urinary tract symptoms | Use when BPH is present with LUTS. |
|
| Z87.44 | Personal history of diseases of the genitourinary system | Use when BPH has been resolved and is no longer present. |
|
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 history of benign prostatic hypertrophy
Essential facts and insights about History of Benign Prostatic Hypertrophy
Primary ICD-10-CM Codes for history of benign prostatic hypertrophy
Decision Criteria
clinical Criteria
- Prostate enlargement without LUTS
Applicable To
- BPH without LUTS
Excludes
- Prostate cancer (C61)
Clinical Validation Requirements
- Prostate enlargement on DRE
- TRUS showing prostate >30g
Code-Specific Risks
- Incorrectly using this code when LUTS are present.
Coding Notes
- Ensure documentation specifies absence of LUTS.
N40.1 - Benign prostatic hyperplasia with lower urinary tract symptoms
Use when BPH is present with LUTS.
Applicable To
- BPH with LUTS
Excludes
- Acute prostatitis (N41.0)
Clinical Validation Requirements
- IPSS score >7
- Documented LUTS such as frequency, urgency
Coding Notes
Document specific LUTS and IPSS score.
Z87.44 - Personal history of diseases of the genitourinary system
Use when BPH has been resolved and is no longer present.
Applicable To
- History of resolved BPH
Clinical Validation Requirements
- Operative report confirming treatment
- Absence of current symptoms
Coding Notes
Ensure documentation states BPH is resolved.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Benign Prostatic Hypertrophy 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 clinical picture., Regulatory: Potential audit issues., Financial: Incorrect reimbursement.
Mitigation Strategy
Use templates for documentation, Regular training on documentation standards
Impact
Reimbursement: Incorrect coding may lead to reduced reimbursement., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Use N40.0 or N40.1 if BPH is still present.
Impact
Using Z87.44 for active BPH.
Mitigation Strategy
Regular audits and coder 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 History of Benign Prostatic Hypertrophy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Benign Prostatic Hypertrophy
Use these documentation templates to ensure complete and accurate documentation for History of Benign Prostatic Hypertrophy. These templates include all required elements for proper coding and billing.
Resolved BPH post-treatment
Specialty: UrologyRequired Elements
- Treatment history
- Current symptom status
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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