Bolster Your BPH Coding Knowledge With This Helpful Guide
Learn which BPH procedure will receive a permanent code in 2026. Chances are a male patient or a patient who is assigned male at birth is likely at some point in their lifetime to experience lower urinary tract symptoms (LUTS) of varying severity, from mild to severe. There are numerous causes of LUTS, and benign prostatic hyperplasia (BPH) is one condition that requires evaluation by a urologist. Continue reading to learn how to code BPH diagnoses and treatment options. Understand Benign Prostatic Hyperplasia When an evaluation begins, BPH may be referenced in the documentation interchangeably with other phrases, such as benign prostatic hypertrophy, enlarged prostate, or benign prostatic obstruction. The “H” in BPH implies hyperplasia or hypertrophy of the prostate, which means the patient is experiencing an increase or enlargement of size or tissue of the prostate. The prostate is located at the base of the bladder, and the urethra runs through it. When the prostate becomes enlarged the urethra may narrow, leading to urinary symptoms like trouble initiating stream, frequency, incomplete emptying, urgency, nocturia, or other symptoms. BPH can also occur without LUTS. Code a BPH Diagnosis Correctly After workup, confirmation, and a documented diagnosis in the patient's medical record, ICD-10-CM codes can be assigned. Diagnosis codes available for BPH with or without urinary symptoms are as follows: You’ll select from the following codes if the urologist diagnoses the patient with a nodular prostate with or without urinary symptoms: The Use additional code notes under N40.1 and N40.3 state “use additional code for associated symptoms, when specified,” and then lists several suggested urinary symptoms, such as: Please note, the list above is not an all-inclusive list of urinary symptoms associated with BPH. Review medical record documentation and verify the conditions with the most up-to-date ICD-10-CM code set for appropriate coding. In the listing of suggested codes, one might notice, some of the suggested symptoms are R codes, located under Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99). Assigning R diagnosis codes might feel like it is breaking coding fundamentals of not reporting sign and symptom codes when a definitive diagnosis has been confirmed. However, coding notes instruct you to report additional diagnosis codes, if known and documented. Also supporting the coding note to report R codes is the coding note under Chapter 14: Diseases of Genitourinary System (N00-N99). This section note designates R codes as Excludes2 codes, meaning it is acceptable to use both the BPH code and the excluded code together, when appropriate. Documenting and coding the patient’s urinary symptoms helps support the acuity and severity of the patient’s condition, as well as the medical necessity of the service provided to the patient and any future medical needs. Report BPH Treatment Options While there is no remedy for BPH, urinary symptoms and further prostate growth may be managed with medications. Medications are usually the first treatment in managing symptoms. BPH medication classifications include alpha-adrenergic blockers, 5-alpha-reductase inhibitors, and phosphodiesterase-5 enzyme inhibitors. Depending on the goals of management and severity of symptoms, there are many name brand and generic medication options available. Alternatively, if medications do not manage symptoms, surgical options are available. Most surgical options are performed through the urethra, such as transurethral resection of the prostate (TURP), which is coded with 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)). The urologist uses a resectoscope during a TURP to resect prostate tissue; this has been the gold standard of BPH management for decades. Available prostate treatment codes include, but are not limited to: Aquablation will be graduating to a permanent CPT® code in 2026 after being a temporary code for 10 years. Look at Life After Treatment Overall, BPH is a nonmalignant condition that could occur at any age after the prostate’s second growth cycle; however, the condition is more likely to occur in men and those that identify as male 50 years old and older. The cause of BPH is unknown and while there is no cure for the condition, symptoms can be managed by medications or surgical intervention. Kelly George, CPC, CUC, Contributing Writer
